American eclectic obstetrics

NLH ODSfilDfifi 1

NATIONAL LIBRARY OF MEDICINE
Washington

Founded 1836

U. S. Department of Health, Education, and Welfare

Public Health Service

AMERICAN

ECLECTIC OBSTETRICS.

bti/

JOHN KING, M. D.,

PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE ECLECTIC
MEDICAL INSTITUTE OF CINCINNATI, OHIO J FORMERLY PROFESSOR OF MATERIA
MEDICA AND THERAPEUTICS IN THE MEMPHIS INSTITUTE \ AUTHOR OF THE
" AMERICAN DISPENSATORY," " WOMAN, HER DISEASES AND THEIR
TREATMENT," " MICROSCOPIST's COMPANION," "CHRONIC
DISEASES AND THEIR TREATMENT," ETC.

Second Edition Revised and Enlarged.

" No one point is more universally denied by tho American people than the EXCLUSIVE RIGHT of
one set of men to judge of and have sole control in anything. Persecution or proscription for opinion'!
Bake is not tolerated in political or religious matters, and certainly should not be in those pertaining to
medicine."

CINCINNATI:
WILSTACH, BALDWIN" & CO.,

No. 143 RACE STREET.

1871.

wo

Entered according to Act of Congress, in the year 1855, by
MOORE, WILSTACH, KEYS & CO.,
in the Clerk's office of the District Court for the Southern District of Ohio.

Entered according to Act of Congress, in the year 1866, by
MOORE, WILSTACH & BALDWIN,
in the Clerk's office of the District Court for the Southern District of Ohio.

i

-

TO

ALL TRUE PRIEUDS

o I

THROUGHOUT THE WORLD,

©his Work

IS RESPECTFULLY INSCRIBED,

BT

THE AUTHOR.

PREFACE.

During the lectures of the Author in the various Sessions of the Eclectic
Medical Institute of Cincinnati, for many years, in the department of Obstet-
rics, a great amount of inconvenience was experienced by the classes, as well
as by himself, from the want of a Text-Book, especially adapted to the
teachings of that school of medicine, known as the American Eclectic; and,
to obviate this embarrassment in the future, as well as to aid in removing
any incorrect views of the tenets of this school, which may have been based
upon improper representations, was the principal design of the Author in
the publication of the first edition of this work. And, although more
especially intended for the benefit of the student, imparting to him practical
information not to be found elsewhere, divested of speculative theory, and
presented in as plain and concise a style as the nature of the subject would
admit, yet it has been highly gratifying to the Author to learn that even
those engaged in practice have consulted its pages with benefit, that the large
edition at first published has been well received by the professsion, and that
a new edition is now loudly called for. And in the preparation of this
Second Edition, his sole aim has been to be useful, and advance as far as lies
in his power the best interests of suffering and afflicted humanity.

In American Eclectic Practice, the mechanical management of obstetrical
cases varies but little, if any, from that advocated and pursued by the profes-
sion generally; but a very marked distinction may be observed in the collat-
eral treatment, which was for the first time presented in a published form
in the first edition of this work, and in which several new agents were intro-
duced, not previously recognized in obstetrical practice. For the last thirty-
two years the writer has been more or less actively engaged in the practice of
his profession, and has made extensive and successful employment of the

vi

PKEFACE.

several measures made known in the present volume; and from the results of
careful experience and close observation, he feels fully justified in recom-
mending these measures as safe, successful, and superior to any other means
yet offered to the medical world — and which have received the commendation
of every practitioner who has given them a fair and unprejudiced trial.

The introduction of Lobelia, Gelseminum, Cimicifuga, Caulophyllum, Ale-
tris, Helonias, Asclepias, and various other agents, together with their com-
pounds and concentrated preparations, into the Practice of Midwifery and
Diseases of Females, by American Eclecticism, has proved to be an important
* addition to the remedies previously known and recognized by the profession,

as, through their means, the sufferings of the sex are prevented to a greater
degree than has ever been accomplished heretofore by any class of practi-
tioners, and the various ailments peculiar to them are more readily and per-
manently removed. The several medicines and compound preparations herein
referred to, and particularly those which are not commonly met with in the
medical works of the day, belong to the Materia Medica of American Eclec-
tics, a description of which, together with their virtues and modes of prep-
aration, may be found in the new edition of the American Dispensatory,
recently published by the Author.

Yet it is not in accordance with Eclectic precepts and teachings to assume
an arbitrary authority in any matters connected with the science of medicine ;
it is the right — it is the imperative duty of every physician to thoroughly
and impartially investigate every subject connected with his profession, no
matter by whom presented; he can not with any degree of justification,
attach his medical faith to the sleeves of any man — he alone is responsible
for the health and lives of his patients — and, after a fair examination of
medical matters, it is equally his right and duty to pursue those views and
measures which he has decided to be correct, carefully avoiding, however,
every means which past experience has demonstrated to be injurious and
deleterious to the human system. This is American Eclecticism, and that
physician only, who rigidly and honorably follows this plan, no matter in
what school he may have graduated, is the true American Eclectic. There-
fore, while not desiring to authoritatively force any partial or sectarian views
and treatment of Midwifery upon the profession, the Author sincerely hopes
hat sufficient credence will be accorded to the statements herein given, as to

PREFACE.

vii

induce others to test and avail themselves of the remedies and treatment
which, in his estimation, arc unequaled by any others known.

In presenting this work as an illustration of the American Eclectic System
of Practice, and in the references to the difference between the Eclectic and
Old School treatment, the Author hopes that he will not be misunderstood
by the intelligent reader. The use of these distinctive terms has been ren-
dered necessary by the existing differences in the courses of practice taught
in different schools; but it has not been his intention to refer to these differ-
ent modes of practice as belonging to radically distinct and independent
systems of medical science. If the progressive spirit of American physi-
cians has led them to the discovery and adoption of many new and important
improvements, they have not become so infatuated with the value and supe-
riority of their new contributions as to have neglected the careful preserva-
tion of the great mass of well established medical science, accumulated by
the labors of European physicians. Like all enlightened and liberal physi-
cians, they aim simply to improve their knowledge and advance the profes-
sion in those directions in which progress is most evidently necessary, without
losing their sympathy and communication with all true cultivators of the
science, and without desiring to be distinguished from the mass of the pro-
fession, except by greater diligence or success in following the instructions
of Clinical experience, and acquiring a more enlarged and accurate knowl-
edge of the therapeutic powers and pharmaceutic preparations of an exten-
sive Materia Mcdica. For our success in the introduction of clinic and
therapeutic improvements, we are mainly indebted to an Eclectic spirit of
liberality, which has discarded the formal routine of authority, for a free
investigation of nature and adherence to the results of the most recent clin-
ical experience. The universal satisfaction with which these improvements
have been received, satisfies us, that ere long they will have the unanimous
sanction of the entire Medical Profession, since they are already, so far as
known and tested, cordially approved of by enlightened physicians, whatever
may have been their previous doctrines or impressions.

The arrangement of the volume is somewhat in accordance with the course
pursued by the writer in his lectures, and is considered by him as being
more especially adapted to the correct advancement of the studeut in this
department of Medical Science. In the preparation of this second edition

viii

PREFACE.

of the work, notwithstanding the various other matters in which the Author
has heen engaged to distract his attention ; as, the preparation of a largo
work on Chronic Diseases, together with his duties as a practicing physician,
and as a medical teacher, etc., his endeavor has been to render the volume as
thorough and perfect, in a practical point, as possible ; but should any omis-
sions or imperfections have escaped his notice, it is hoped they will prove of
minor importance, and be indulgently treated by every liberal mind.

No pains have b*een spared to obtain and present every new and practically
useful fact in Obstetrical Practice, and the Author has availed himself of the
writings and observations of others, as far as in his power, quoting from them
whenever the ideas advanced corresponded with his own, and to which he
takes this opportunity of acknowledging his great indebtedness. Nor can he
allow this occasion to pass without tendering his thanks to Mr. George K.
Stillman, of this city, wood engraver, for the able manner in which he has
executed his part of the work. J • K.

Cincinnati, February, 1866.

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AMERICAN

ECLECTIC OBSTETRICS.

DP A. R T I .

ANATOMY OF THE PARTS CONCERNED IN THE FUNCTION
OF GENERATION.

CHAPTER I.

BONES OP THE PELVIS.

By Midwifery or Obstetrics, we understand that department of
Medicine which has especial reference to the Treatment and Man-
agement of Females, from the moment of conception, to the
period of weaning the infant, and which comprises three distinct
conditions, viz.: Utero-gestation, Parturition, and the subsequent
suckling of the Offspring. But previous to these conditions,
during their presence, and subsequently, the Female is subject to &
number of abnormal changes, peculiar to the sex, several of which
are attended with much risk, destroying health and even endan-
gering life, and all of which, together with their appropriate
treatment, should be well understood by every Obstetrician ; yet
as these latter do not come directly under the head of Midwifery
proper, but rather under a separate department, " The Diseases of
Females," we shall not treat upon them in this work.

"Without a correct knowledge of the anatomy of the Female
Pelvis, and the organs proper to it, it will be impossible to com-
prehend the normal or abnormal changes which may take place
during pregnancy and the process of delivery, as well as their
correct treatment; neither will we be able to discriminate and
2

10 AMERICAN ECLECTIC OBSTETRICS.

treat the diseases peculiar to the sex, with any degree of certainty.
A reference, therefore, to the anatomy of the bones, and soft parts
of the Pelvis, is very important in a treatise on Obstetrics.

Fig. 2.

Adult Male Pelvis.

The PELVIS is a bony structure, of conoidal shape, with the
base upward, situated at the lower part of the body, between the
last lumbar vertebra, and the upper portion of the ossa femora,
and which consists, in the adult, of four bones, viz.: the sacrum,
the coccyx, and the two ossa innominata — the peculiar form and
connection of which give rise to three cavities or canals, termed
the Pelvic Cavity, the Superior strait, and the Inferior strait.

The SACRUM, or os basilare, is situated on the superior-posterior
part of the pelvis, immediately below the last lumbar vertebra, with
which its superior surface articulates, above the os coccyx, and
between the two ossa innominata, to each of which it is united by
means of ligaments. It is pyramidal or triangular in shape, its
anterior face being smooth and concave, and its posterior irregular
and convex. The concavity of its anterior face is from above down-
ward, and its depth, in a well formed pelvis, is such, that a perpen-
dicular let fall from a line, drawn from the apex to the base of the
bone, upon the deepest point of the concavity, will measure from
nine to twelve lines, or from three-quarters of an inch to an inch ;

BONES OF THE PELVIS.

11

this concavity is termed the hollow of the sacrum; it may, however,
vary very much, and when too strait, or too much curved it pre-
sents an obstacle to the easy passage of the child's head through
the excavation. '

Adult Female Pelvis.

A. The Sacrum.

B. The Os Coccyx.

C C. The Two Iliac Bones.
D D. The Two Pubic Bones.
E E. The Two Ischiatic Bones.
1 1. The Crest of the Ilium.

2 2. The Anterior-superiorSpinous processes of

the Ilia.

3 3. The Acetabula or Cotyloid Cavities.

4 4. The Tuberosities of the Ischia.

5 5. The Obturator Foramina.

6. The Promontory of the Sacrum.

During childhood, the os sacrum is composed of five distinct
pieces, termed false vertebral, which become firmly consolidated at
adult age, and leave five surfaces nearly quadrilateral, and which;
are separated from each other by four projecting transverse seams
or ridges, at the original points of separation. At the sides or
lateral portions of these seams, are a series of openings, termed
foramina, usually four on each side, which terminate outwardly in,
large grooves converging to each other, and which- are named the
anterior sacral foramina and grooves, and which serve to lodge and
transmit the sacral nerves coming from the spinal canal. The
nervous cords lying in these shallow grooves, are comparatively
secure from injurious pressure during labor, yet it is sometimes the
case, that during the passage of the child's head, these sacral nerves

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AMERICAN ECLECTIC OBSTETRICS.

are exposed to much pressure, which, as in other instances of com-
pression upon a nerve, occasions a numbness, pain or severe cramps
in the parts to which they are distributed, as in the thigh, leg, or
foot. This usually ceases, as soon as the pressure is relieved by the
expulsive progress of the head, but when the nerves have been
severely bruised or compressed, the unpleasant effects may remain
for some time after delivery. In some cases, where there are
agonizing pains, with symptoms of exhaustion, it may become
necessary to deliver with the forceps.

External to these sacral foramina, and on the projecting crista?
which separate the grooves, arise the asperities, which serve as
points of attachment to the fibers of the pyriform muscles.

The posterior surface of the sacrum is convex from above down-
ward, rough and unequal, presenting on the median line, four
eminences or spinous processes, which decrease in size as they
descend ; on either side of these eminences, there are four open-
ings or foramina, smaller than those on the anterior surface, which
are named the posterior sacral foramina, and which transmit the
posterior branches of the sacral nerves. External to these foramina
are a number of processes, which serve as points of attachment to
several muscles and ligaments.

The lateral surfaces of the sacrum are rough, thick above,
but diminishing as they descend, and in the recent subject, are
covered with cartilage, which unites them to the iliac bones. The
superior portion of each lateral surface, which articulates with the
ilium, is broad and irregular ; and the inferior edges are thin and
nearly sharp, and give attachments to the greater and lesser sacro-
sciatic ligaments.

The base of the sacrum is about two and a half inches thick, and
about four inches in breadth, and articulates with the last lumbar
vertebra in such a manner, as to form a projection at the superior
strait, called the promontory of the sacrum or the sacro-vertebral angle.
At the posterior surface of the base, is a triangular aperture, which
is the commencement of a canal, traversing the whole extent of
the sacrum, which gradually diminishes in size as it descends, and
in which the spinal marrow is continued. The apex of the sacrum
is small, having an oval surface which articulates with the base of
the coccyx.

The texture of the sacrum is spongy and cellular, and covered
externally by a thin lamina of compact tissue ; its length is about
four and a half inches. The union of the sacrum with the ilia is

BONES OF THE PELVIS.

13

so arranged, as to give great firmness and security to its position,
so that it may sustain without injury, any weight from within out-
ward, and from above downward; the sacrum entering the ilia like
a wedge, having its superior portion broader than its inferior, and
its anterior point of union broader than its posterior.

The OS COCCYX or cuckoo bone, so named from its resem-
blance to the beak of the cuckoo, is the caudal extremity of the
spinal column. It is a small, single, triangular bone, the base of
which points upward, and unites with the apex of the sacrum by
means of an oval articular surface, which, it is said, admits of a
backward motion of the coccyx, when pressed by the fetal head,
to the extent of half an inch. Yet the firmness by which the
coccyx is fastened to the ischia, through means of the sacro-sciatic f
ligaments, is unfavorable to any such mobility, except by severe
and continued pressure. The coccyx is flattened, curved from
behind forward, and bears some resemblance to the sacrum, though
it difi'ers from it in being much smaller, about one and a half inches
in length, and in having no spinal canal. Its anterior surface is
slightly concave and rough, ar'd supports the lower extremity of
the rectum ; its posterior surface is convex and unequal, is sepa-
rated from the skin only by the posterior sacro-coccygeal ligament,
and has inserted into it some of the fibers of the glutseus magnus
muscie. Its lateral edges are rough, giving attachment to the
small sciatic ligaments, and the ischio-coccygeus muscle. Its apex,
generally projecting in front, gives attachment to the fibers of the
external sphincter ani muscle. In childhood the coccyx is formed
of three or more bony pieces, but which become consolidated in
adult age. The internal structure of this bone is cellular, and
covered externally by a very delicate lamina of compact texture.
It is called by the various names of huckle, knuckle, or whistle-
bone, crupper bone, etc.

The OSSA INNOMHSTATA, or nameless bones, and sometimes
termed the haunch bones, are two in number; they are the largest
and most irregular of the pelvic bones, are of a quadrilateral form,
contracted in their central portions, and form the lateral, anterior
and inferior portions of the pelvis. Each one of these bones con-
sists, in early childhood, of three distinct pieces, but which become
firmly consolidated in the adult. These are called the os ilium, the
os ischium, and the os pubis, whose union takes place in the acetab-
ulum or cotyloid cavity ; the dividing lines of these three bones

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AMERICAN ECLECTIC OBSTETRICS.

meet nearly in the center of the acetabulum, giving the upper and
outer two-fifths to the ilium, anteriorly one-fifth to the pubis, and
the remaining two-fifths to the ischium. For purposes of descrip-
tion, and as a matter of more easy reference, the above division is
preserved by anatomists.

The OS ILIUM, hip or coxal bone, forms the upper and lateral
portions of the pelvis; it is the largest bone of the os innominatum,
is flat, broad, and nearly triangular in shape. The base or body
of the bone is situated at the thick and narrow part which forms
the upper portion of the acetabulum, and the large expansion or
wing which passes from it, upward and outward is termed the ala.
The external or femoral surface of the ilium is convex, and is
called the dorsum ilii, or gluteal region, having the three glutei
muscles lying upon it; and presents below, in its inferior and outer
part, a cavity for the head of the femur, called the acetabulum or
cotyloid cavity.

The internal or abdominal portion, called the venter or costa,
presents at the upper part a broad, smooth, concave surface, termed '
the internal iliac fossa, on which the internal iliac muscle is situated,
and which supports the large intestine; in one of these fossee the
child's head is placed during the operation of turning. Below, is
a prominent ridge or curved line, running from behind forward,
that is, from the superior part of the sacro-iliac junction to the top
of the pubis, forming part of the linea ilio pectinea, or ilio-pubic line
which defines the superior strait. The excavation above this ridge,
which is also named the brim of the pelvis, is termed the upper or
superior basin or pelvis, while the cavity below is termed the
lesser or lower basin or pelvis, or the pelvic cavity.

The superior or upper convex edge of each wing, is called the
crest, or crista ilii; this crest is rough and thick, for the insertion
of muscles, is shaped like the letter /, being thicker in front and
behind than in the middle, and terminates in front, in an anterior-
superior spinous process, from which some of the muscles of the
abdomen and thigh arise, and into which others are also inserted —
and behind, in a posterior-mperior spinous process, underneath each
of which processes is a semi-circular notch, terminating inferiorly
in an anterior and a posterior-inferior spinous process; all of which
processes serve as points of origin and insertion of muscles and
ligaments. The surface which articulates with the sacrum is rough
and irregular. Immediately below the posterior-inferior spinous

BONES OF THE PELVIS.

15

process is an arched sinuosity, forming at the union of the ilium
and sacrum, the great sciatic notch, which is two inches in depth,
and terminates inferiorly, by an acute and sharp spinous process
called the spine of the ischium, which points backward and slightly
inward.

The OS ISCHIUM, os sedentarium, or seat bone, occupies the
lower part of the pelvis, and its base or body forms the inferior
portion of the cotyloid cavity, and is very thick and strong. The
internal surface of this bone is smooth and slightly concave, and
is called the plane of the ischium ; it is nearly an equilateral triangle,
and is three and a half inches in length. The planes of the two
opposite ischia incline toward each other, forward and downward,
and which convergence exerts an influence on the fetal head during
labor, repelling or deflecting the vertex toward the pubic arch, as
the head approaches the outlet of the pelvis.

The spine of the ischium, proceeding from the posterior portion
of the os ischium, furnishes a place of attachment for the lesser
sacro-ischiatic or sacro-sciatic ligament ; beneath this process, is a
concavity or notch, named the lesser ischiatic, or sciatic notch, in
which the tendon of the obturator internus plays. Below this, is
the inferior or lower portion of the ischium, or that part upon
which the body rests when in a sitting posture ; it is rough, thick
and strong, and is termed the tuberosity of the ischium ; the great
sacro-sciatic ligament arises on the inside of this tuberosity, and its
outside, inside and central surfaces give origin to various muscles.

Passing obliquely from without inward, and from below upward,
from the tuberosity of the ischium, is a flat process of bone called
the ramus of the ischium, which unites with the descending branch
or ramus of the pubis, and assists in forming the pubic arch. In
the female pelvis, the anterior edge of this ramus is beveled or
turned outward, thus affording more space for the passage of the
fetal head under the pubic arch. The opening in the anterior
part of the pelvis, formed by the ischium and os pubis, is called
the thyroid, sub-pubic, or obturator foramen, through which pass the
obturator vessels and nerves, and to its inner side is attached the
adductors and the obturator externus. This foramen is rounded
in man and triangular in woman.

The OS PUBIS, otherwise variously called the shear bone, the
cross bone, the bar bone, or pecten, is situated at the inner and

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AMERICAN ECLECTIC OBSTETRICS.

anterior part of the os innominatum, and is joined to its fellow of
the opposite side by a union or articulation termed the symphysis
pubis. It may be divided into, the body, a horizontal, and a
descending ramus or branch. The body of each os pubis is placed
transversely before the anterior part of the ilium ; and from the
side of the body proceeds the horizontal ramus, going outward to
meet the ilium. The superior face of the os pubis is flat, and
upon its outer and anterior portion is its spinous process, from
which two eminences proceed, one passing outward to be lost in
the acetabulum ; the other, running along the inner margin of the
horizontal ramus, is called the crest of the pubis, or crista pubis.
This ridge is sharp and elevated, and forms the anterior third of
the linea ilio-pectineal eminence. The descending ramus of the
pubis passes downward to unite with the ascending ramus of the
ischium. As with the rami of the ischia, the anterior edges of the
pubic rami are beveled or turned outward, affording a sufficiently
large and free opening for the fetal head to pass. The descending
ramus is connected with its fellow of the opposite side, toward
their origin, by a ligamentous substance, called the triangular liga-
ment, which is a part of the interpubic ligament, binding the two
pubes together, and rendering the arch of the pubis broader or
lower, and also stronger. The arch of the pubis is formed on the
anterior and inferior part of the pelvis, by the union of the two
pubic rami; it is much wider In the female than in the male.

The anterior face of the body of the os pubis is concave and
rough, for the origin of the adductor muscles of the thigh ; its
posterior surface is nearly flat and smooth, but contributing a little
to favor the general concavity of the pelvis. The largest or thick-
est portion of the pubic bone is that employed in the formation of
the acetabulum; the next thickest portion is at the symphysis
pubis, from which it becomes gradually thinner as it extends
toward the obturator foramen.

It will be seen that the ilium forms no portion of the inferior
strait, but enters largely into the superior — also that the ischium
forms no portion of the superior strait, but onlji,of the inferior —
while the pubic bones form a large portion of both straits. Hence
a deformity of the ilium would affect only the brim; a deformity
of the ischium would implicate only the outlet; but a distorted
pubes, would necessarily involve each of the straits.

SYMPHYSES AND LIGAMENTS OF THE PELVIS.

17

CHAPTER II.

SYMPHYSES AND LIGAMENTS OP THE PELYIS — THEIR MORBID CHANGES AND TREATMENT.

The Pelvic Bones are united together by articulations and liga-
ments, which never separate during labor, or at any other time, so
long as they are in a normal condition. The articulations are four
in number, and have received the name of Symphyses, each
symphysis being designated according to the bones which form it ;
thus, we have the symphysis pubis, the sacro-iliac symphysis, and the
sacro-coccygeal symphysis.

The SYMPHYSIS PUBIS, or pubic articulation is formed
between the bodies of the ossa pubis, the articular surfaces of
which are clothed by a thick layer of fibro-cartilage; this passes
across from one bone to the other, and is so strong as to admit
rather of the disruption of the bone than of its own tissue. At the
center of the symphysis, and toward the posterior third of the
fibro-cartilage, are two smooth, polished, oblong articular surfaces,
covered by a cartilage, and lined by a synovial membrane, which
arrangement is difficult to detect in man, or even in woman,
except when she has died shortly previous to, 9r soon after, par-
turition.

The ligaments which strengthen the pubic articulation are four
in number: 1, the anterior pubic ligament, lying on the anterior
face of the symphysis pubis ; 2, the posterior pubic ligament, which
is an expansion of the periosteum ; 3, the superior pubic ligament,
or supra-pubic ligament, which supports the superior edge of the
pubes, and effaces all its inequalities ; and, 4, the inferior, or sub-
pubic ligament, which is remarkably strong and thick, and of a
triangular form ; by some it is considered as a continuation of the
inter-pubic ligament. It adds greatly to the strength of the artic-
ulation, and its inferior edge constitutes the crown of the pubic arch.

The SACRO-ILIAC SYMPHYSIS or junction, is the articula-
tion formed by the corresponding rough surfaces of the sacrum
and ilium, and of which there are two — one on the right, and the
other on the left superior lateral portion of the sacrum. Each of
these articulating surfaces has a covering of cartilage, which is
thicker on the sacrum than on the ilia, and between which exists a
thick, yellowish fluid, which serves to lubricate the parts ; and in

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AMERICAN ECLECTIC OBSTETRICS.

children and pregnant women, there is said to be a synovial mem-
brane in each joint.

The ligaments which aid in strengthening this articulation, are
four in number: 1. The posterior sacro-iliac ligament, which fills
nearly the whole of the deep excavation comprised between the
sacrum and the two posterior spinous iliac processes ; their union
constitutes a pyramidal ligament, capable of immense resistance.
This ligament arises from the posterior and inferior spinous pro-
cesses of the ilium, and from the margin of the sacrum and coccyx,
and passes outward and downward to be inserted into the tuber-
osity of the ischium ; it is broad at its origin, but narrow and
thick at its insertion. 2. The anterior sacro-iliac ligament, which
extends transversely from the sacrum to the ilium ; it is an expan-
sion of the periosteum of the pelvis, which passes in front of the
articulation, and adheres to it but feebly. 3. The superior sacro-
iliac ligament, which passes transversely from the base of the
sacrum to the ilium ; it is very thick and strong. 4. The inferior
sacro-iliac ligament, which arises from the posterior-superior spinous
processes of the ilium, its superior fibers being inserted below the
third sacral foramen, while the lower portion is inserted anteriorly
into the tubercle of the extremity of the edge of the sacrum, and
posteriorly to the great sacro-sciatic ligament.

The foregoing articulations are still further strengthened by
other ligaments, and which assist also in completing the parietes
of the pelvic cavity, as: 1. The posterior, or greater sacro-sciatic
ligament, which arises from the internal lip of the tuberosity of
the ischium, and from its ascending ramus ; it is situated obliquely
in the posterior inferior part of the pelvis, is contracted in its cen-
ter and expanded at its extremities, and passes upward and back-
ward to be inserted into the margin of the coccyx and sacrum,
and into the posterior-inferior spinous processes of the ilium. 2.
The anterior, or lesser sacro-sciatic ligament, which is placed in front
of the greater sacro-sciatic ligament, which it crosses : it arises
from the free margin of the sacrum and from all the bones of the
coccyx, and is inserted into the summit of the spine of the ischium.
These two ligaments convert the great sciatic notch into two open-
ings or foramina; the upper foramina is the largest, irregularly
oval, and transmits the pyriformis muscle, the great sciatic nerve,
gluteal, ischiatic and internal pudic vessels and nerves, while the
lower foramen is of a long triangular shape, and gives passage to
the internal obturator muscle and internal pudic vessels and nerves.

SYMPHYSES AND LIGAMENTS OP THE PELVIS.

19

The obturator or sub-pubic ligament, may likewise be mentioned ;
it is inserted by its internal semicircumference to the posterior face
of the ascending ischiatic ramus, and by its external semicircum-
ference to the outline of the obturator foramen. This ligament
closes the obturator foramen, with the exception of an opening at
its upper part, through which pass the obturator vessels and nerves.
The obturator muscles are attached to the two surfaces of this
membrane.

The SACRO-COCCYGEAL SYMPHYSIS, is the articulation
between the apex of the sacrum and the base of the coccyx ; this
union is effected by a cartilaginous substance, similar to that which
exists between the vertebrae, and is strengthened by two liga-
ments ; 1. The anterior sacro-coccygeal ligament, which arises from
the inferior extremity of the sacrum, extends over the whole ante-
rior face of the coccyx, and is inserted into its extremity. 2. The
posterior sacro-coccygeal ligament, which arises from the last sacral
bone, and is inserted into the second bone of the coccyx. These
ligaments maintain the connection of the sacrum and coccyx, and
oppose all mobility or displacement. Some authors consider that
they admit of motion of the coccyx in an antero-posterior direc-
tion to the extent of half an inch, and not laterally ; but from the
firmness with which the sacro-sciatic ligaments fasten this bone
toward the os ischium, this can not be a common occurrence;
beside, it is known that when the coccyx has been forcibly pressed
backward during labor, great pain and suffering have been the
consequence.

There are, in early life, coccygeal articulations which unite the
several pieces of the coccyx with each other ; their consolidation
takes place more rapidly in males than in females.

There are other articulations common to the pelvis, which, how-
ever, have no direct agency with parturition, and to which it will
be necessary merely to refer ; they are, 1. The sacro-vertebral artic-
ulation, or the junction between the base of the sacrum and the
inferior face of the last lumbar vertebra; this articulation is an
amphiarthorosis. 2. The ilio-femoral articulations, or the junctions
of the femoral bones with the ilia, in the cotyloid cavity.

It has long been a question whether the articulations of the
pelvis are possessed of any motion. An examination of the

20

AMERICAN ECLECTIC OBSTETRICS.

method by which the bones are united with each other, and tht
solidity of their union, would lead us to consider them as perfectly
immovable, at least in the ordinary conditions of life. Yet, whei
we reflect that they are supplied with synovial membranes, whicb
are only found in movable articulations, we may admit them t(
possess, under certain circumstances, a slight degree of motion, at
for instance, the shock of a fall from a hight, upon the feet, i«
much diminished in its influence upon the body and brain, by v
slight mobility.

There is no doubt, but that during pregnancy or parturition-
there may be a relaxation, or separation of the symphyses, espe
cially of the symphysis pubis, but it is an uncommon event, am
one which is seldom met with, and which, in my opinion, dependt
upon a diseased condition of the parts themselves, the result o*
falls, blows, or other causes. For were it a circumstance common
to parturient women, it would be impossible for them to walk 01?
exercise immediately previous, as well as subsequent to confine-
ment (acts which are accomplished daily), from the fact that an
appreciable degree of mobility would not only render it impossible
to walk, but likewise very painful to stand. The tissues about the
joints may, probably, become softer, and perhaps more movable
during pregnancy and parturition, yet any appreciable relaxation
or separation must necessarily be unfavorable, and owe their origin
to some disease not connected with these conditions.

When relaxation does take place, the symphyses become swollen,
and sometimes dilate so much as to separate the bones which aid
in their formation, permitting them to glide over each other, and
occasioning uneasiness and fatigue in the movements of the female,
with difficulty of standing. Should labor come on, the auxiliary
muscles of the uterus, not having any longer a fixed point of inser-
tion in the vacillating bones of the pelvis, draw the symphyses
apart, producing great agony ; and the female, dreading the pain
occasioned by their contraction, remains passive, and allows the
uterus slowly and difficultly to expel its contents, unaided by her
efforts. Instances of this kind have taken place, and have always
proved a source of much distress and suffering, causing more or
less intense pain on motion, with much difficulty in moving the
lower extremities, and an inability to stand.

Occasionally, there is not only a relaxation, but likewise an
actual separation of the parts, giving rise to most intense suffering,
inflammation, peritonitis, and all the symptoms of 'simple relaxa-

SYMPHYSES AND LIGAMENTS OP THE PELVIS.

21

tion in a more aggravated form, greatly endangering life. This
separation may be accidental, resulting from the powerful efforts
made by the patient to expedite her delivery, or it may ensue from
the employment of the lever or forceps in extracting the fetal head,
or even from the operation of turning to deliver by the feet. Some-
times it is congenital, and usually accompanies exstrophy or extro-
version of the bladder, of which it may probably be the result.

There is but little protection given by ligaments to the anterior
part of the sacro-iliac symphyses, the only ligament of any size
boing the anterior sacro-iliac; the principal ligaments are placed

0 i the outer edge of the joint, and any tendency to open at its
inner margin is prevented by the ligaments of the symphysis
pubis. Hence a separation of the pubic bones will occasion a
relaxation or separation of the sacro-iliac symphyses : and when
h separation takes place in consequence of the pubic junction
being cut or ruptured, the sacro-iliac symphyses immediately open
considerably, the effect of which is, pain, inflammation, and if
uot remedied, caries of the bone, suppuration of the parts, and
hectic fever.

TREATMENT. — In either relaxation or separation of the sym-
physes of the pelvis, it will be absolutely necessary for the patient
to remain quiet, and in a horizontal position for a long continued
period of time; the inflammatory symptoms which may be present
must be subdued by applications of either cold or tepid water, which-
ever may produce the most beneficial influence, as determined by
their employment, and emollient poultices, together with the inter-
nal means usually administered in other cases of inflammation. A
decoction of "White Oak Bark has been found very efficacious, when
implied locally, on the subsidence of the inflammatory symptoms.

1 he diet should be light. "When the inflammation has been sub-
died, or in cases where there is no disposition to inflammation, the
return of the inter-articular cartilages to their normal condition
may be attempted, by means of bandages around the pelvis, the
p itient still maintaining the horizontal position; over the articu-
lations compresses may be kept and retained there, having them
constantly moistened with a decoction of "White Oak Bark, or of
the Root of Geranium Maculatum, or with a solution of Tannin in
Port Wine. The pressure of the bandage should beat first, gentle,
but gradually increased. Cupping or blistering is inadmissible.
The diet should be strengthening and rather generous, but suited

22

AMERICAN ECLECTIC OBSTETRICS.

to the condition of the digestive powers; a good animal diet is of
service, and if much debility, some wine, or chalybeate draughts.
The bowels should be kept regular, obtaining one evacuation every
day, and never more than two. The surface of the body should
be frequently bathed either with a weak, alkaline wash, or a mix-
ture of vinegar, water and salt, and in drying, considerable friction
should be made with a flannel cloth. If the general system becomes
impaired, preparations of Iron, Quinia, or the officinal Compound
Syrup of Stillingia, with Iodide of Potassium may be used, as the
symptoms indicate. In using the latter compound, I generally add
half an ounce of the Iodide to one pint of the Syrup, the dose of
which is one fluidrachm, to be taken in half a gill of water, and
repeated three or four times a day.

The patient should not be advised to attempt walking too soon,
and when it is considered prudent to test her strength, it must be
done with great care. A well padded leathern girdle should be
fixed around the hips, as tightly as the patient can bear, and
kept in its place by straps passed under the thighs; the upper part
of the body should also be supported on crutches, in order to lessen
the weight and pressure of the trunk on the articulations, which
must, at first, be unable to maintain its whole weight.

CHAPTER III.

STRAITS AND CAVITIES OF THE PELVIS.

The union of the several bones already considered by means of
their symphyses or articulations, forms the Pelvis, which is of a
conical shape, with its base looking upward and forward, and its
apex pointing downward and inward. Tile internal surface of the
pelvis is divided into the upper basin, or greater pelvis, located above
the superior strait, and the lower basin, or lesser pelvis, sometimes
termed the pelvic cavity or excavation, and which occupies the space
comprised between the superior and inferior straits — so called
because they are rather more contracted than the space between
them. The greater pelvis is bounded posteriorly by the lumbar
vertebrae, laterally by the alse ilii, and anteriorly by the abdominal
parietes; the lesser pelvis is marked posteriorly by the sacrum and
coccyx, laterally by the ischia, and anteriorly by the pubes.

STRAITS AND CAVITIES OP THE PELVIS.*

23

Between these two cavities is an aperture of an elliptical or
curvilinear triangular form, somewhat resembling the shape of a
playing-card heart, with its base resting on the sacrum, and at
which location a prominent ridge is observable, which has received

the names of ilio-pubie line, linea ilio -pectineal protuberance, and brim
of the pelvis; it is formed by the crest of the pubis, and the ridge
which is continuous along the lower part of the alse ilii, and which,
together with the promontory of the sacrum, constitutes the
SUPERIOR STRAIT. In a well formed pelvis its circumference
measures from fourteen to sixteen inches. The diameters of the
superior strait are as fol-
lows: 1. The antero-posterior,
or sacro-pubic, or conjugate
diameter (a a, Fig. 4), extend-
ing from the superior poste-
rior edge of the symphysis
pubis to the promontory of
the sacrum, measures from
four to four and a half inches.
2. The transverse, or bis-iliac
diameter (b b, Fig. 4), passing
from one ilium to the other,
and crossing the antero-pos- Diameters of the Superior Strait.

. . -,. , . i , A A. Antero-posterior C. C. Oblique Diameters,

tenor diameter, at a Tight Diameter. A. C. Sacro-cotyloid Space,

angle, measures five inches. B B. Transverse Diameter.

In the recent subject, this diameter is lessened by the psose and iliac
muscles, which overhang the sides of the brim. 3. The oblique diame-
ters (c c, Fig. 4), passing from the ilio-pubal line, or side of the
brim just above the acetabulum, to the sacro-iliac symphysis of the
opposite side, measure, each, from four and a half to five inches.
The one passing from the right ilio-pubal line to the left sacro-iliac
symphysis, is called the right oblique diameter; and that which passes
from the left ilio-pubal line to the right sacro-iliac symphysis, is
called the left oblique diameter. 4. The sacro-cotyloid space, or
diameter (a c, Fig. 4), extending from the center of the pro-
montory of the sacrum, to the ridge just above the cotyloid
cavity, measures from three and three-quarters of an inch to
four inches.

The articulation of the spinal column with the pelvis, is such,
that the axis of the superior strait is not parallel with that of the

24

AMERICAN ECLECTIC OBSTETRICS.

Fig. 5. body. If a piece of pasteboard be

accurately cut and fitted to the
pectineal line or superior strait, it
will represent the plane of that
strait (c H, Fig. 5), and will be
neither horizontal or vertical, but
will form with a horizontal line,
an angle of about 54° to 56°, varying
more or less according to the posi-
tion of the body. The axis of the
superior strait will, therefore, be an
imaginary line passing through the
center of the plane at right angles
(a b, Fig. 5), and will be found to
extend from the neighborhood of
the umbilicus, downward and back-
ward, to the central portion of the coccyx.

A B. Axis of the Superior Strait.
C H. Plane of the Superior Strait.
C D. Horizontal Line.
C E. Plane of the Inferior Strait.
E G. Axis of the Inferior Strait.

The INFERIOR or PERINEAL STRAIT, also termed the
outlet of the pelvis, is bounded posteriorly by the apex of the
coccyx, laterally by the inner edges of the ischiatic tuberosities,
and the sacro -sciatic ligaments, and anteriorly by the rami of the
ischia, and the inner edges of the pubic arch. Its circumference
measures between thirteen and fourteen inches. The conformation
of this strait is apparently very irregular, but if a sheet of paper
be applied to it, and its outline traced by a pencil, it will be found
of an oval form, with its large extremity pointed backward, and
broken by the projection of the coccyx. The diameters of the
inferior strait are as follows:

1. The antero-posterior diameter (a a, Fig. 6), extending from the
lower edge of the symphysis pubis to the apex of the coccyx,
measures four inches, but in some women it may be increased to
five, in consequence of the regression of the coccyx. 2. The
transverse, or bis-ischiatic diameter (b b, Fig. 6), extending from one
tuberosity of the ischium to the other, measures four inches.
3. The oblique diameters (c c, Fig, 6) extending from the center of
the great sacro-sciatic ligament of one side, to the point of union
between the ascending ramus of the ischium and descending ramus
of the pubis, measure, each, from four to four and a half inches.
At the period of delivery, this diameter may be slightly increased
owing to the mobility of the sacro-sciatic ligaments.

STRAITS AND CAVITIES OF THE PELVIS.

25

That which passes from the
right lateral anterior region to
the left lateral posterior, is called
the right oblique diameter; and that
which passes from the left lateral
anterior region to the right lateral
posterior, is called the left oblique
diameter.

An imaginary line extending
from the lower edge of the sym-
physis pubis to the coccygeal
apex, will represent the direction

Fig. 6.

Diameters of the Inferior Straits.

A A. Antero-posterior diameter.
Of the plane Of the inferior Strait BB, Transverse diameter.

(c e, Fig. 5), and a line passing 1%^T1^Z^Z'

thrOUgh the Center Of this plane 2- pub"= Symphyses and Pubic Crest.

. . * 3. Anterior Superior Spinous Process of the Ilium.

at right angles or perpendicular 44. Obturator Foramina,
to it, will give the direction of the axis of the inferior strait (e
g, Fig. 5), which extends from the center of the strait to the first
sacral bone, and crosses the axis of the superior strait near the
center of the pelvic cavity, forming at their point of contact a
very obtuse angle; it is parallel with the axis of the body. The
directions of these axes of the two straits should be well under-
stood, as they determine the direction which the fetal head takes
in passing through the pelvis, and which course should be fol-
lowed whenever delivery has to be effected by instruments; the
curved direction of these two axes through the center of the pelvis,
may be considered as the true axis of the pelvis (g k, Fig. 1).

In consequence of the arrangement of the pelvic bones, which
causes this variation in the direction of the axes of the two straits,
the pelvic contents are prevented from falling downward, which
might, otherwise, be the result, either from their own gravity, or
from the pressure of the abdominal viscera above them.

The PELVIC CAVITY or EXCAVATION", includes all that
space occupied between the superior and inferior straits; it is
bounded posteriorly by the sacrum, the coccyx, the sacro-iliac sym-
physes, and a portion of the sacro-sciatic ligaments ; anteriorly, by
the symphysis-pubis, pubic bones and the internal obturator fossae;
and laterally, by the two inclined acetabular planes, the sciatic
openings, and the sacro-sciatic ligaments. The canal of this cavity
possesses a curvature corresponding to the curve of the sacrum,
and which gives to it a greater extent than that of the straits.

26

AMERICAN ECLECTIC OBSTETRICS.

The axis of this canal, represents the route taken by the fetus in
its expulsion through the cavity, and should be well understood by
the practitioner, if he expects to meet with success in the opera-
tions which may be necessary to effect artificial delivery. The
axis of the pelvis is not formed of two straight lines, nor does it,
as supposed by Cams and others, represent the arc of a circle; but
it has been well determined by M. Cazeaux, who observes (Fig. 7) :
FlG 7 "To form an exact idea of

the general disposition of the
pelvic cavity, it seems best to
cut that canal by a series of
planes, passing from the point
q' (the point of intersection of
the planes of the superior and
inferior straits), to the points
p q r s t, of the anterior face
of the sacrum. Each one of
these planes will determine the
opening of the pelvic cavity at
that point. Now, to determine
with precision the direction of
the general axis of the excava-

A B. Plane of the Superior Strait. .. .,

I 0. Plane of the Inferior Strait. tl0n> lt »e necessary to erect

Q'. The point where these two planes would meet, if a perpendicular to the ffeOmet-

prolonged.
M N. The Horizontal Line.
E F. The Axis of the Superior Strait.
G K. The Axis of the Pelvic Cavity.
P Q R S T. Various points taken on the Sacrum to K) along the extremities Ot these

show the plane of the excavation at each point, perpendiculars. This line (o K)

is curved, and is called the general axis of the pelvic cavity. It is
easy to see that this line is nearly parallel with the anterior face of
the sacrum, and its extremities are lost in the axes of the superior
and inferior strait. This curve represents exactly the axis of the
whole excavation ; that is to say, the line which the fetus traverses
in passing through the pelvis."

The depth of the pelvic excavation, posteriorly, along the sacrum
and coccyx, is from five to six inches ; laterally, three and a half
inches; anteriorly, along the os pubis, one and a half to two inches.
Its diameters are :

1. The antero-posterior diameter, passing from the symphysis
pubis to the center of the sacrum, measures four and a half inches,
or more.

rical center of each one of these
sections, and to draw a line (a

STRAITS AND CAVITIES OF THE PELVIS.

27

2. The transverse diameter extending from the plane of one
ischium, to that of the other, measures about four and a half
inches.*

There is considerable difference in form and texture, between the
pelvis of a female, and that of a male. (Figs. 2 and 3.) The
female pelvis is not so strong nor so thick as that of the male, and
contains less osseous matter; in the male the long diameter of the
superior strait, is from before, backward, while in the female it is
from side to side; in the male, the brim is more triangular, in the
female, more oval. In the female the ilia are more distant ; the
tuberosities of the ischia are also further apart from each other,
and from the coccyx, and the space between the pubes and coccyx
is greater than in the male. The sacrum of the female is broader
and more curved than in the male, and the superior articulations
are more distant from each other, occasioning a peculiarity in her
walking, apparently rendering it more difficult for her to preserve
the center of gravity. The symphysis pubis is not so long in the
female as in the male, and the rami of the pubes and ischia are
smoother on their inner face, and have their anterior edges turned

*It may be proper to remark here, that Prof. Meigs describes two planes of the
inferior strait — an anterior plane occupying about one-third of the anterior portion of
the outlet, and a posterior plane comprising the remaining two-thirds of the posterior
portion; these intersect each other, forming an angle of 140°. The anterior portion of
the posterior inclined plane, is first depressed by the advance of the child, and then
the posterior edge of the anterior inclined plane; and when the edges of the two
planes become depressed, the child passes between them, after which they assume their
original places.

Beside these two planes of the inferior strait, accoucheurs likewise recognize two
lateral inclined planes, situated on each side of the anteroposterior median line of the
interior of the pelvis. The anterior inclined planes commence at the sacro-iliac sym-
physes, and occupy all the space between these points and the symphysis- pubis, and
passing downward and forward in front of the ischiatic- spines, over the obturator
foramina, they terminate on the anterior edge of the pubic and ischiatic rami, and at
the pubic symphysis ; the posterior inclined planes commence likewise at the sacro-
iliac symphyses, and occupy all the space between those points and the middle line of
the sacrum, then pass downward and backward behind the ischiatic spines, over the
eacro-sciatic foramina and ligaments, and terminate upon the posterior edges of the
ischiatic tuberosities, the inferior edges of the sacro-sciatie and coccygeo-ischiatic
ligaments, and the coccygeal apex. They are divided into right and left anterior
and posterior inclined planes, of which the anterior are the longest and widest, and
occupy the greatest space in the pelvic cavity. By many authors these planes are
said to exert an immediate influence upon the movements of the fetal head, effecting
rotation, and directing the presenting part of the fetus.

28

AMERICAN ECLECTIC OBSTETRICS.

more outwardly; the obturator foramen is more triangular in the
female ; and the cotyloid cavities are more widely apart.

The following dimensions of the male and female pelvis are by
Meckel.

In the Male. In the Female.
Inches. Lines. Inches. Lines.

" The transverse diameter of the great pelvis
between the anterior- superior spinous pro-
cesses of the ilia 7 8 8 6

Distance between the cristse of the ilia ..8 3 9 4
Transverse diameter of the superior strait .4 6 5 0
Oblique diameter of the superior strait ..4 5 4 5
Antero-posterior diameter of " " ..4 0 4 4
Transverse diameter of the cavity .... 4 0 4 8

Oblique diameter of the cavity 5 0 5 4

Antero-posterior diameter of the cavity ..5 0 4 8
Transverse diam. of the lower strait or outlet 3 0 4 5
Antero-posterior diam. of the " " " 3 3 4 4

"The latter may be increased to 5 inches, from the mobility of
the coccyx."

The above dimensions of the straits and cavity of the female
pelvis are assumed as the standard, and any considerable deviation
from these measurements, may present an obstacle to the progress
of delivery, and the pelvis is then said to be vitiated or malformed.

It may be proper to make a brief reference to some of the ves-
sels and soft parts which cover the pelvis, especially those which
occupy its cavity. In the greater or false pelvis, we find anteriorly,
the muscles and the anterior parieties of the abdomen, which
assist in completing this basin ; laterally, the iliac fossae are filled
with the internal iliac muscles ; and posteriorly, are the psoas
major and minor muscles, which pass downward along and
on the sides of the lumbar column, and along the pelvic brim,
to be inserted into the trochanter minor. These muscles, in
connection with the iliac veins and arteries, are so arranged as to
contract the size of the transverse diameter of the superior strait,
to even an inch less than its true length, thus apparently present-
ing its oblique diameter as the largest; but these muscles are capa-
ble of great compression, especially when they are completely
relaxed by flexing the thighs upon the pelvis, and hence in the

DEFORMITIES OP THE PELVIS.

29

majority of cases, they present but little obstacle to the passage of
the fetus.

The pelvic excavation is lined by fascia, which assist in dimin-
ishing its diameters; it is also lessened posteriorly, by the sacral
plexuses of nerves, the pyriform muscles, the hypogastric blood-
vessels, and the rectum ; anteriorly, by the bladder, the obturator
nerves and vessels, and the internal obturator muscles; and in its
vertical diameter, by the floor of the pelvis or perineum, which is
a muscular membranous plane closing the pelvis inferiorly, acting
in antagonism to the diaphragm and abdominal muscles, and on
whose median line are the urinary, generative and fecal or anal
orifices. Inclosed within these soft parts are the vagina and
uterus. The muscles of the perineum, are — the sphincter aniy sur-
rounding the lower part of the rectum, and which arises from the
coccyx, and is attached to the center of the perineum ; the sphincter
or constrictor vagince — which arises from the body of the clitoris,
and is attached to the center of the perineum ; it is about fifteen
lines wide, and surrounds the anterior opening of the vagina, act-
ing as a sphincter to it — the erector clitoridis arises from the
ascending ramus of the ischum, covers the inferior face of the
crus clitoridis, and is inserted into the upper part of the crus and
body of the clitoris, it draws the clitoris downward and backward ;
and the transversalis perincei arises from the fatty cellular mem-
brane which covers the tuberosity of the os ischium, and is
inserted into the perineal center; it keeps the perineum in its
proper place.

CHAPTEE IV.

DEFORMITIES OF THE PELVIS.

Any remarkable deviation from the standard measurements of
the pelvis produces a malformation or deformity of it ; yet, it does
not follow, that every slight variation should be viewed as
deformity, but only those instances in which it may so far depart
from its normal form as to render it extremely difficult, or even
impossible to deliver the full grown fetus by the natural passage.
A pelvis, the small diameter of which measures three and a half
or four inches, may, in case there be no unusual enlargement of
the fetal head, admit of its safe passage at full term with but very

30

AMERICAN ECLECTIC OBSTETRICS.

little difficulty; below this measurement, say from three inches to
three and a-half, the forceps will undoubtedly be demanded ; if it
be still smaller than this, the induction of premature delivery
would be prudent and justifiable, and if the fetal head should be
unable to pass, the perforator would be required. In cases, how-
ever, where the measurement of the small diameter does not
exceed one inch and a half, the perforator can not be used with
safety, and in these instances the Cesarean section is recommended
as the only chance for the mother's life.

The more general causes of vitiated or malformed pelvis, are
rickets and mollities ossium. Rickets is probably the most fre-
quent cause ; this is a disease common to children, especially those
of a strumous diathesis, and is very seldom met with in adults.
In this affection, the bones become very much softened, in conse-
quence of the deficiency of the calcareous matters natural to them,
owing to their absorption or non-deposition ; and in connection
with the disease there is most usually an arrest of development of
the bones, in which the pelvis, instead of becoming properly
developed with the growth of the female, retains its infantile
condition, and thus presents a permanent obstacle to delivery.
From these circumstances, the bones curve unnaturally in various
directions, especially those upon which there is much pressure, or
upon which is exerted a long continued action of the muscles ; and
the pelvis in particular, which sustains the weight of the trunk,
becomes more or less deformed, according to the duration and
severity of the disease, and the deformity continues even after the
disease has been cured. Most generally this disease commences
in the bones of the inferior extremities, and gradually extends
itself to the pelvis, the spinal column, etc.

TREATMENT.— Children, therefore, who are affected with
rachitis, should be kept in a state of rest, in a reclining position;
the bed on which they rest should be soft, and made of the leaves
of Sweet Fern (Comptonia asplenifolia), and Dogwood (Cornus
fiorida), which exert a beneficial influence on the disease; the limbs
and body should be frequently bathed with salt and water, or
brandy and salt, to be applied with considerabla friction. The diet
should be principally animal, and the medication which I have
found the most advantageous, is the administration of Phosphate
of Iron, from two to four times a day, in connection with the fol-
lowing compound : Take of the roots of Buckhorn Brake (Osmunda

DEFOKMITIES OF THE PELVIS.

31

regalis), bruised, four ounces, Solomon's Seal (Convallaria mul(iflora),
bruised, two ounces, Boiling water enough to reduce the whole to a
paste of a little more consistence than the white of egg. To
this add Conifrey root (Symphytum officinale), Yellow Dock root
(Bumex crispus), Bittersweet, bark of root (Celastrus scandens),
Prickly Ash berries (Xanthoxy ion fraxineum), Caraway Seed (Carum
carui), of each, finely bruised, one ounce, White Sugar, two pounds,
best French Brandy, three pints. The dose of this compound, is
from a fluidrachm to a fluid ounce, three or four times a day, accord-
ing to the age of the patient. A liniment applied to the joints
and along the spine once or twice a day will be found valuable in
this affection; I usually employ the following: Linseed oil, two
ounces, Oil of Sassafras, Oil of Wintergreen, Oil of Origanum, Gum
Camphor, of each, one ounce. Rub together in a glass or Wedge-
wood mortar.

Children, and especially female children, who are disposed to
rickets, should never be allowed to creep or walk at too early a
period, lest pelvic deformity occur as a consequence.

Mollities Ossium, or Malacosteon, is the usual cause of those deform-
ities which take place during adult age. It also consists in an
undue softening of the bones, owing to the absence of their salts,
especially the phosphate of lime, and is usually connected with a
gouty or rheumatic diathesis ; sometimes it is the result of mer-
curial treatment. This disease is gradual in its progress, and the
deformity resulting from it, may occur in women who have previ-
ously given birth to several children, and who may subsequently
become so deformed in the pelvis, as to render delivery by the
natural passage absolutely impossible.

The cause of the deformity, in either rickets or mollities ossium,
is essentially the same; thus, the sacrum being softened by either
disease, will from the superincumbent pressure, be forced from its
natural position, occasioning an increase or decrease of the pelvic
diameters, at the superior strait, inferior strait or in the pelvic cavity.
Or the oblique diameter of the pelvis, or its antero-posterior diam-
eter may be diminished, in consequence of the acetabula being
driven inward; these alterations may exist singly, or may be vari-
ously combined.

In cases of Mollities ossium, the TREATMENT will be similar
to that named for rickets, with the addition of the internal adminis-

32

AMERICAN ECLECTIC OBSTETRICS.

tration of the officinal compound Syrup of Stillingia, to each pint of
which, half an ounce of Iodide of Potassium must be added. How-
ever, the disease is seldom cured.

Deformities of the pelvis may arise from other causes than those
to which I have just referred; thus, the very erroneous practice of
forcing children to walk, by means of go-carts, baby-jumpers, and
the like, may at an early age give rise to malformations which will
continue irremediable through life. When children are allowed to
walk voluntarily, gradually perfecting this exercise as their locomo-
tive organs acquire energy, strength and development, deformi-
ties rarely occur. A child carried constantly on one arm, may
cause a malformation, and I am acquainted with a lady, who has a
deformed pelvis, originating from carrying her mother's children,
during her girlhood, constantly resting them on the one hip.
Carrying heavy burdens in early life, or remaining too long in one
position, before the bones have acquired the necessary firmness,
are very apt to cause this kind of malformation.

An old unreduced luxation of the femoral bones, caries of the
bones, exostoses, the result of syphilitic or rheumatic affections,
imperfectly consolidated fractures, and pelvic tumors may con-
tribute to deformity of the pelvis, or occasion a diminution in its
capacity. Sometimes it is impossible to determine the origin of the
deformity.

Pelvic deformity is more common to the females of Europe than
to those of this country — which is probably owing to the fact, that
our countrywomen are better nourished, take more healthful exer-
cise, and are not exposed to the many causes, common to Europe,
which contribute to destroy health among the working and indi-
gent classes. Many of the cases which are met with in this country
are among females, whose early life was passed in some portion of
Europe. But, there is no doubt, that as our population increases,
together with an increase of poverty, factory-working, etc., these
results will cease to be uncommon among us.

The various forms given to the pelvis by the above causes, are
very numerous, and must ever vary, according to the multitudinous
local accidents, severity and duration of the causes, etc., and to enter
into a minute description of them, or to arrange them into distinctive
classes, is almost impossible, nor, indeed, is such an attempt abso-
lutely necessary. Some of the more common deformities have,
however, been classified by authors as follows : 1st. The abnor-

DEFORMITIES OF THE PELVIS.

33

mally large pelvis, or where there is an excess of dimension ; 2d.
The dwarfish pelvis, or where there is a diminution of dimension ;
3rd. The unequally contracted pelvis; and 4th. The obliquely dis-
torted pelvis.

1st. The abnormally large pelvis or excess of the dimensions of the
pelvis. This can not properly be termed a deformity, yet its
presence may give rise to many accidents, which it is the duty of
the accoucheur to prevent or relieve. Females, in the unimpreg-
nated state, in whom this condition exists, are very liable to various
uterine displacements, which often prove extremely difficult to rem-
edy. And during pregnancy, from the absence of due support to
the uterus above the superior strait, this organ readily descends
into the pelvic cavity, producing a sense of weight, with various
painful and unpleasant symptoms ; as painful or difficult micturi-
tion, constipation, obstinate tenesmus, hemorrhoids, pains, cramps,
etc., the necessary result of compression of the bladder, rectum, and
the bloodvessels and nerves which line the pelvis, by the enlarged
and prolapsed uterus.

Again, during parturition, and especially if the female should exert
herself by bearing down before the os uteri be sufficiently dilated,
the uterus may be forced through the inferior strait ; or, dilatation
being perfected, together with frequent and energetic uterine con-
tractions, the fetus, from the want of proper resistance, may pass
easily through the pelvic straits and cavity, and suddenly present
itself at the perineum, which has not yet been sufficiently distended,
and lacerate it. Or, should the perineum yield without laceration,
the sudden evacuation of the uterus renders the female exceed-
ingly liable to hemorrhage, inversion, or other accidents. These
inconveniences, however, may be readily obviated by a careful
practitioner; the recumbent position during the first months of
pregnancy and during labor, will generally overcome them.

2d The dwarfish pelvis, or diminution of the dimensions of the
pelvis. This deformity, although not very common to this country,
is occasionally met with. The pelvis retains the proper form and
dimensions externally, yet its internal cavities are very much
diminished in extent, varying from a quarter of an inch to an inch,
in each of the diameters. This kind of deformity is not connected
with rickets nor malacosteon; nor can it be attributed to arrest of
development, as the pelvis is usually well formed, and bears no

34 AMERICAN ECLECTIC OBSTETRICS.

resemblance to the undeveloped pelvis of the child; its causes are
not well understood.

The difficulty in giving birth to a child, depends entirely upon
the degree of deviation of the pelvic dimensions from the standard
size, and the proportions existing between the diameters of the fetal
head and the pelvis; yet a pelvis smaller than the average size, may
occasion no other difficulty than a tedious, disagreeable, painful,
and perhaps exhausting labor.

The diagnosis of this deformity is always difficult to correctly
determine, unless we have had its existence indicated by a previous
labor, and in cases where we suspect its presence from the size of
the patient, a certainty may be acquired by an examination. All
the diameters of the pelvis are equally contracted in the dwarfish
pelvis, hence it has been termed " the equally contracted pelvis,"
and as no favorable changes can be effected in consequence of the
impossibility of bringing the long diameter of the head to corre-
spond with the long and uncontracted diameter of the pelvis, as in
the unequally contracted pelvis, very great obstacles to delivery are
presented, and most labors result fatally to both mother and child.

3d. The unequally contracted -pelvis, or partial deformities, in
which there is a great alteration or disproportion between the vari-
ous parts, so that during labor the female is subject to much suffer-
ing, and even death, and the practitioner frequently becomes
embarrassed. The deformity may exist in the greater pelvis, the^
lesser pelvis, the superior strait, the inferior strait, or in two or more
of these united.

The most usual mal-
formations in the great-
er pelvis are an exag-
geration of the curva-
ture of the lumbar
column, presenting a
deviation or projection
of its anterior surface;
or the wings of the ilia,
or the iliac fossae may
be turned too much
Elongation of the Antero- Posterior Diameter of outwardlv These de
the Superior Strait. » ... "

tormities do not mate-
rially affect either pregnancy or parturition, although when exces-

DEFORMITIES OF THE PELVIS.

35

sive, they undoubtedly influence the presentations of the fetus, and
sometimes occasion a permanent obliquity of the uterus, which
may prevent the natural expulsion of the child. ( Figs. 8 and 9.)

The lesser pelvis, or pelvic cav- Fig. 9.

ity, may be deformed by a defi-
ciency or excess of one or more
of its diameters, and which must, ]
consequently, influence in a great-
er or less degree, the diameters
of the superior and inferior
straits — more frequently those of
the superior strait. Diminution of the Antero-Posterior

Theantero posterior diameter of £IAMETER 0F THE Superior Strait, and
. , ., -i n% , i Elongation of the Transverse Diameter.

the superior strait may be anected

by the advancement of the promontory of the sacrum toward the
center of the strait, in which case we usually find an excessive
curvature of the sacrum, which is sometimes so great, that its apex
looks up toward the pubic arch, interfering with the anteroposte-
rior diameter of the inferior strait; or, while the base of the sacrum
diminishes the antero-posterior diameter of the superior strait, in
consequence of its abnormal projection, its apex may be thrown
backward, and thus increase the same diameter of the inferior
strait. Sometimes the sacrum may be unchanged, but the pubes
will be found retreating toward the sacrum, diminishing the antero-
posterior diameter of the brim ; at other times, both the change
in the sacrum and pubes may exist simultaneously.

The transverse diameter of the superior strait may be diminished
in consequence of one side of the pelvis being much narrowed — or
the horizontal rami of the pubes may approximate toward each
other, becoming nearly parallel, and with this there may likewise
exist an approach of the iliac bones. The forward projection of
the pubes caused by this deformity, increases the antero-posterior
diameter of the brim. A diminution of the transverse diameter of
the brim, is seldom accompanied by an increase in that of the infe-
rior strait; although it may be present where the contraction is
the result of an upward and backward dislocation of the femur,
drawing the ischiatic tuberosities and pubic rami more distantly
. apart. The transverse diameters of both straits may be lessened
by improper pressure upon the pelvis at a time when, in conse-
quence of disease, the bones are softened.

The oblique diameter of the superior strait may be decreased by

36

AMERICAN ECLECTIC OBSTETRICS.

one side of the pubes projecting inwardly, while the other projects
outwardly, or the iliac bones may turn inwardly. If in the first
deformity, the long diameter of the fetal head presents in the direc-
tion of the great oblique diameter of the brim, and the transverse
occupies the diminished diameter, labor may terminate safely with-
out artificial assistance.

The superior strait may not be at all changed, while the inferior
strait is much diminished ; thus, the antero-posterior diameter of
the inferior strait may be lessened by the apex of the sacrum turn-
ing within and upward toward the pubic arch ; or the coccyx may
project forward too much.

The transverse diameter of the inferior strait may be contracted
in consequence of the approach of the ischiatic tuberosities toward
each other, as well as of the sides of the pubic arch, which will render
it absolutely impossible for the head of the child to pass, or even
the hand of the accoucheur. This deformity is the most to be
dreaded ; the head readily passes through the brim and pelvic
cavity, and becomes arrested only at the outlet, and the practi-
tioner, after delaying for a length of time, in hope of its expulsion,
is finally obliged to employ the forceps or perforator.

The oblique diameters of the inferior strait may be changed by
the maldirection of the ischio-pubic branches.

These malconformations of the two straits may exist singly, and
sometimes in combination, but in opposite directions ; thus, if one
strait be contracted, the other will be enlarged. The consequences
which must arise from these various changes, will be evident to
the student who compares the diameters of the child's head with
those of the bony passages through which it must pass.

The pelvic cavity may be deformed, 1st, by a turning backward
of the pubes; 2d, by the abnormal length of the symphysis pubis,
which retards delivery by preventing the head from engaging in
the arch of the pubes ; 3d, by the too great or small curvature of
the sacrum; 4th, by exostosis, and fibro-cartilaginous morbid pro-
ductions. Various other forms, than those referred to, may be
assumed by the pelvis, which, however, can not be satisfactorily
classified, as they must ever vary, according to circumstances.

4th. The obliquely distorted pelvis. (Fig. 10.) This deformity is
usually dependent upon an arrest of development of one or the
other side of the sacrum ; more generally the right side, and which
occasionally extends to, and includes the ilium. N'segele' was
the first writer who seems to have noticed this deformity, and of

DEFORMITIES OF THE PELVIS.

37

whose remarks M. Cazeaux Fig. 10.

has given us the following in
his work on Midwifery, trans-
lated edition, p. 434 :

" The peculiar characteris-
tics of these deformed pelves
are as follows —

" 1st. Complete anchylosis
of one of the sacro-iliac sym-
physes, or partial fusion of
the sacrum and one of the
iliac bones.

" 2d. Arrest of development, Obliquely Distorted Pelvis,

Or defective development Of *D wn'ck t'le anter°-P0Steri°r diameter traverses from
*■ the promontory of the sacrum to the left acetabulum ; the

the lateral half of the Sacrum, left oblique diameter is also lessened, while the right is

and defect in the amplitude normal"

of the anterior sacral foramina of the anchylosed portion.

"3d. On the same side, diminished length of the ilium, with dimi-
nution in the extent of the sciatic notches of this bone ; that is to
say, the distance from the anterior-superior spinal process of
the ilium, to its posterior-superior spinous process, as also the
length of a line drawn from a point at the pelvic inlet, cor-
responding with the sacro-iliac junction, if it existed, along the
linea innominata, and the linea ilio-pectinea to the symphysis
pubis, are shorter than the (same distances) on the other side. But
farther upon the anchylosed bone, the part corresponding with
the articular surface, which is continuous without interruption,
with the sacrum, is not so high, and descends to a shorter distance
than it does on the opposite side, and than it would do in a bone
normally formed; or to express myself more clearly, if on the
anchylosed side we suppose the ilium and sacrum separated, or
reunited only by the interposition of a fibro-cartilaginous disk,
such as exists in the normal joint, the articular surface or the
reunion of the two bones would be found less long, and would
descend less low than it would on the non-anchylosed side, or upon
the pelvis normally constituted.

"4th. The sacrum seems to be pushed toward the anchylosed
side, and it is toward that side that its anterior face is more or
less turned, while the symphysis pubis is pressed toward the oppo-
site side, a disposition which prevents the symphysis pubis from

38

AMERICAN ECLECTIC OBSTETRICS.

being directly opposite the promontory of the sacrum, and gives it
an oblique direction.

"5th. On the anchylosed side, as much of the internal surface of
the ilium as concurs to the formation of the pelvic excavation is
flattened, and where considerable vitiation exists, it is almost
entirely plane, so that a line drawn from the middle or even from
the posterior end of the linea innominata, along the body and the
transverse branches of the pubis to its symphysis, will be nearly
straight. "We have never seen at the lateral half of the anterior
wall of the pelvis, of which we now speak, any inclination inward,
nor have we ever especially noticed that sort of fracture of the
horizontal branch of the pubis, which is observed in pelves deformed
from the effects of malacosteon in adults.

" 6th. The other lateral half of the pelvis, that is to say, the one
in which there exists a sacro-iliac synchondrosis, also differs from
the normal condition. At first sight, in examining the pelvis
under consideration, and especially where the obliquity is consider-
able, it is easy to induce oneself to believe in the normal conform-
ation of the non-anchylosed half; but this opinion is not correct;
thus, let us suppose two pelves equally contracted, with this differ-
ence only, that in one the left sacro-iliac symphysis is anchylosed,
in the other, the anchylosis is on the right side; let a section of
each be made so as to pass through the middle of the sacrum and
the symphysis pubis — if now we undertake to fit the right half of
the first pelvis to the left half of the second, so that the cut surfaces
shall cover each other, we will discover that the pubic bones are
separated by a distance of from eight to twelve lines. Thus the
lateral half of the pelvis, which is free from anchylosis, participates
not only in the abnormal situation and direction of the bones, but
also in their irregular form, in such a way that in measuring this
half, a line drawn from the center of the promontory of the sacrum,
along the linea innominata, and pectinea, to the symphysis pubis,
would be at its posterior half more curved, and at its anterior half
less curved than in a pelvis well formed.

" 7th. It follows from this, that the pelvis is obliquely contracted,
that is to say, in a direction which would intersect a line passing from
the anchylosed joint to the cotyloid cavity of the opposite side,
while the extent of the last-mentioned line is not diminished but
may be increased where the obliquity is very marked. In conse-
quence of this, the shape of the superior strait (that is to say, an
imaginary surface passing along the linea innominata and the

DEFORMITIES OF THE PELVIS.

39

linea pectinea over the sacrum), and the shape of the middle of
the excavation (situated midway between the superior and inferior
strait, called the apertura pelvis media), would both resemble, prop-
erly speaking, an oblique oval when examined in front — the trans-
verse or small diameter of which would be represented by the con-
tracted oblique diameter of the pelvis, while its great or longitudinal
diameter would correspond to the other oblique diameter. On this
account we may, as far as the form is concerned, term this variety
of pelvic deformity the obliquely oval pelvis.

" That the distance from the sacral promontory to the point
corresponding to one or the other cotyloid cavity (the distance
sacro-cotyloid), as well as the distance from the obtuse point of the
sacrum to the spine of the ischium on either side, is less on the
side where the anchylosis exists.

" The distance from the tuberosity of the ischium on the side of the
anchylosis to the posterior-superior spinous process of the ilium of
the opposite side, as well as the distance between the spinous process
of the last lumbar vertebra, and the anterior-superior spinous
process of the ilium on the side of the anchylosis, are smaller than
the same measurements on the opposite side.

" The distance from the inferior edge of the symphysis pubis to
the posterior and superior spinous process of the ilium, when the
anchylosis exists is greater than that extending from the same point
of the symphysis pubis to the posterior-superior spinous process, of
the opposite side.

"The walls of the pelvic excavation converge, in a certain
oblique manner, from above downward, and the pubic arch is more
or less contracted, so as to give it a resemblance to the male pelvis.
These two conditions, as well as the contraction of the sciatic notch,
the diminution of the distance existing between the spines of the
ischium, and the one-sided and defective development of the sacrum,
bear a direct proportion with the degree of obliquity.

" Finally, on the flattened side, the cotyloid cavity is placed more
directly in front than is observable in the normally-formed pelvis,
while on the opposite side, it looks almost directly outward, in such
a way, that when examining the pelvis in front, the eye rests directly
upon the cotyloid cavity of the flattened side, while the edge of
the one, on the other side, can only be seen, or at. least, very little
of its cavity.

" In order to give to those who never have seen a pelvis of this
kind, as accurate an idea as possible, we will remark that when

40

AMERICAN ECLECTIC OBSTETRICS.

first seen, they give us the impression that the deformity has been
occasioned b}r a pressure acting from above downward, and from
without to within, in an oblique direction upon one of the lateral
halves of the anterior pelvic walls, and upon one of the cotyloid
cavities, while, at the same time, the other half seems to have been
compressed on its posterior portion from without inward.

" Another peculiarity of this variety of deformed pelvis is, that
they differ from each other only in the degree of their obliquity,
and at the point where the sacrum is soldered to the ilium, while
in every other respect (that is to say, in reference to the principal
peculiarities of the deformity), they resemble each other as much
as two eggs. It is on this point that a skillful person, not knowing
this peculiarity, would be disposed to take two different specimens,
presented to his inspection, for the same, and it would be difficult
to convince him of his error.

" The condition of the bones of the pelvis (exclusive of the varia-
tions already mentioned), as it regards their strength, their volume,
their texture, their color, etc., is exactly similar to that of healthy
bones, such as are observed in young persons exempt from all deform-
ity. It is for this reason that we find on these bones none of the signs}
either as it regards form, etc., which are met with, as the consequence
of rickets or malacosteon of adults. If we divest our mind of the
existing deformities, the pelvis which we have seen, would seem to
resemble, in general, the healthy pelvis. The majority of them
belong to the medium-sized pelvis, while the others are either under
or over the average size. In no case that we have specially noticed,
have we discovered the least sign of the existence of rickets; in
none have there appeared any of the phenomena, or accidents, or
morbid modifications, which usually precede or follow the English
disease, or the mollities ossium after puberty. Nowhere have we
been able to establish the injurious effects of external causes, such
as falls, blows, etc., and never has there existed any antecedent pain.
It has not been proved, in any of the cases which we have specially
examined, that there existed any lameness. In one case only, we
thought in seeing the person walk, we observed a slight limp,
but other connoisseurs present at the examination, did not
observe it, and the parents, and all the family of the person
in question, assured us positively, that they had never remarked
any lameness.

In the pelvis of this kind, with the lumbar vertebrae attached,
the vertebral column was strait in the lumbar region ; in other

MALCONFORMATION OF THE PELVIS.

41

cases, it inclined to the side exempt from anchylosis. In all the
pelves of our collection, provided with lumbar vertebrre, the anterior
face of the bodies of the vertebrae was more or less turned toward
the anchylosed side."

The anchylosis of the sacro-iliac symphysis, above-named, as a
peculiarity of this deformity, is usually so perfect, that the articula-
tion can not be discovered ; and the two bones appear as one, with-
out any perceptible line of demarkation between them.

CHAPTER V.

INDICATIONS OF MALCONFORMATION OF THE PELVIS.

Undoubtedly the greatest earthly happiness consists in a domes-
tic life, where harmony and co-operation can be maintained ; and
there is nothing so truly calculated to embitter it, and render it a
source of constant wretchedness to husband, wife, and relatives, as
a knowledge of the existeuce of pelvic malconformation in the wife,
rendering her incapable of giving birth to a full-grown fetus ; and
to determine such conformation and capability, in the otherwise
marriageable female, physicans are often consulted. It is, there-
fore, highly desirable that every practitioner should be thoroughly
acquainted with all the symptoms and indications necessary to deter-
mine the presence as well as the extent of a pelvic deformity — for
should he decide incorrectly, from lack of proper information,
and thus cause the parties to engage in a contract for life, the
responsibility of the death of the female, accruing therefrom, would
rest solely upon him. Or, as is sometimes the case, the pregnant
woman may require his knowledge to correctly ascertain the extent
of malformation, that a course may be pursued to preserve both the
parent and child, if possible — at all events the mother — also, whether
there would be safety in allowing gestation to continue its full term,
or in the induction of premature delivery.

"Various causes may give rise to a suspicion of pelvic deformity,
as the pre-existence of rickets, fractures, unusual shortness of the
inferior extremities, or an inequality in their length, as well as an
inequality in the hight of the hips, etc.; a short female with long
arms, when compared with the rest of the body, projecting chin,

4

42

AMERICAN ECLECTIC OBSTETRICS.

and short, crooked legs, has also been named among those disposed
to pelvic malformation.

In the investigation of this matter, the physician should make
himself as thoroughly acquainted as possible with the previous his-
tory of the patient, even from her infancy ; the presence of scrofulous
symptoms, or rickets, or any lameness or difficulty in walking at
any antecedent period, must be carefully inquired into ; and if
there should be found any spinal curvature, or shortening or incur-
vation of the inferior extremities, the age at which these changes
occurred should be noticed ; though it must be remembered, that
pelvic deformity is by no means a constant accompaniment of either
of these last named conditions. In sixty-nine cases of spinal deform-
ity, reported by M. Bouvier, there were but twelve cases where
pelvic deformity was present. Should there be present an inequality
in the length of the inferior extremities, it must be ascertained
whether this arises from dislocations, or improperly united fractures
independent of rickets, or whether it be owing to rickets, or molli-
ties ossium.

The above indications, however, though they may occasion a sus-
picion of some existing deformity, are, of themselves, insufficient to
give a precise idea of its extent or character ; yet when they are
present, they afford competent grounds for further and more accu-
rate examination. For this purpose there are various methods rec-
ognized; as the measurement of the pelvis by instruments designed
therefor, termed callipers, or 'pelvimetry; or by the employment of
the hand. The first is termed instrumental pelvimetry, the latter,
manual pelvimetry ; and by the term pelvimetry is understood, a
process having for its aim the measurement of the various diam-
eters and extent of the pelvis.

The principal object for which pelvimeters have been used, is to
ascertain the capacity of the superior strait, which is the fetal
entrance to the pelvis, and more particularly, the extent of its antero-
posterior diameter, though the dimensions of other parts may
likewise be determined by some of them. The pelvimeters most
usually employed, are Coutouly's, Stark's, Baudelocque's, Mad.
Boivin's, Simeon's, and Stein's; some of which are for external pel-
vic measurement, and the others for internal.

Baudelocque's pelvimeter is for external examination, and is
most commonly preferred to any others yet invented for that pur-
pose. It {Fig. 11) consists of two movable metallic branches or
arms, curved externally in a semicircular form, and of sufficient

MALCONFORMATION OF THE PELVIS.

43

concavity to embrace the hips, or antero-posterior diameter of the
pelvis. One extremity of these arms is straightened for the dis-
tance of about five inches, and, at its superior portion, is attached
to its fellow by a hinge, while the
other, or free extremity, terminates
in a knob, or button. At the infe-
rior portion of the straightened arms
of the compass, commences its curva-
ture, and at this point a graduated
scale is attached, which moves in a
groove, and indicates the degree of
separation of the free extremities.
The instrument should always be
applied to the naked body. In an
examination, one of the knobs must
be placed on the first spinous process
of the sacrum, which will be found
a short distance below the hollow
Of the loins, and the Other must be Baudelocque's Pelvimeter.
placed on the symphysis pubis, or in the separation of the labia
majora at the most elevated point of the anterior commissure of
the vulva; and in effecting this, the skin must be carefully drawn
upward, so as to reach, as nearly as possible, the upper part of the
symphysis pubis, or else an error of several lines may be made.
This position of the instrument indicates the distance from the
posterior edge of the spinous process of the sacrum to the anterior
surface of the symphysis pubis, which, in a well-formed pelvis,
will be seven inches. But, in order to determine the precise extent
of the antero-posterior diameter of the superior strait, the thick-
ness of the sacrum, two and a half inches, as well as that of the
symphysis pubis, half an inch, must be subtracted from the external
measurement, seven inches, and which will give four inches as the
length of the diameter sought.

From the fact, however, that the knob of the posterior extremity
can not always be correctly placed upon the first spinous process
of the sacrum, and that there is more or less variation in the thick-
ness of the soft parts over which the instrument is to be applied }
as well as of the bones, and especially in the latter cases, where
there has been an arrest of development, the measurement of the
antero-posterior diameter of the superior strait, obtained by Baud-
elocque's pelvimeter, can not be depended upon as being definitely

44

AMERICAN ECLECTIC OBSTETRICS.

certain ; neither can the instrument be rendered useful in the detec-
tion of other varieties of malformation, whether dependent on
exostosis, projection of the sacral promontory, or other causes.
And although its use is recommended in cases where minute accu-
racy is not required, and in those unmarried females in relation to
whose pelvic dimensions the physician is consulted, in each of
which instances its employment may aid us in our diagnosis; yet
a reliance solely upon its indications is, under all circumstances,
exceedingly imprudent and hazardous.

These objections to Baudelocque's pelvimeter, occasioned the inven-
tion of Coutouly's pelvimeter, which, unlike the former, is designed for
the internal measurement of the pelvis. It is composed of two
straight steel arms, parallel with each other, and which slide with
equal facility7, the one upon the other ; these terminate in two raised
extremities, and when introduced into the vagina, one of the extrem-
ities is applied against the symphysis pubis, and the other against the
promontory of the sacrum; the application of which, however, is
exceedingly difficult to effect with accuracy. To the horizontal branch
is attached a scale, which indicates the exact amount of separation of
the two extremities. The introduction of this instrument is difficult,
always attended with more or less pain, and rather disgusting to female
delicacy; all of which render its employment very objectionable.

The pelvimeter of Coutouly has undergone several modifications,
though the same objections still remain. The improvement of this
instrument, by Prof. M. Van Huevel, at Brussels, is considered supe-
rior to any other. The following description of it is given by Tucker :
Fig. 12. "This instrument is composed of two

metallic rods, a a and b b, (Fig. 12), united
by means of a joint, so arranged as to allow
the extension of the rods at pleasure, at the
same time that this joint may be tightened
by means of a nut-screw. The rod a a,
intended to be introduced into the vagina,
is curved anteriorly, and flattened at its
extremity in the form of a spatula; the
other rod, b b, is not so long, and is tra-
versed at one extremity by a rod, c, mova-
ble backward or forward, by means of a
screw. In applying this instrument, the

female is placed upon her back, with the
VAN Hu«v«'8 Pelvimeter. legg and thigh8 we]] flexed> geparated

MALCONFORMATION OF THE PELVIS.

45

as widely as possible. The point on the skin corresponding to the
upper edge of the symphysis pubis, should be marked with a dot
of ink ; at the same time, a similar mark may be made to desig-
nate the position of the ilio-peetineal eminence, for the purpose of
measuring the oblique, as well as the antero-posterior diameter of
the superior strait. This being done, one or two fingers should be
introduced into the vagina, and placed against the sacral promon-
tory; when this has been found, the internal rod, a a, is to be
inserted into the vagina, and carried along the fingers to the pro-
montory of the sacrum, against which the broad extremity of the
rod is to be placed. In this position it may be firmly held by hook-
ing the thumb of the hand introduced into
the vagina, over the hook attached to the
rod a a. When this rod has been accu-
rate^ placed, the button extremity of the
rod c, should be fixed upon the dot of ink,
indicating the superior edge of the sym-
physis pubis. When the point of union
between the two rods has been made
firm, by tightly screwing the nut, the
instrument may be withdrawn, and the
distance from the extremity of the rod c
to that of a a, may be ascertained. But
in order to obtain the length of the sacro-
pubic diameter, we must subtract the
thickness of the pubis, and to do this, it
must be measured by re-introducing the
instrument, as is seen in Fig. 13. The
distance first ascertained, minus the thick- Van Hueyel's Pelvimeter.
ness of the pubis, will give us the exact length of the antero-
posterior diameter of the pelvic brim.

" The length of the oblique diameter may be ascertained in a
similar manner. In this case, the extremity of the rod a a, must
be placed against the sacro-iliac junction, while that of the rod c
will rest on a point a little external to the iliac artery. If the
sacro-iliac junction can not be reached, we may measure, instead
of the oblique diameter, the distance sacro-cotyloid, which will
give us every measurement of importance, since, where the
oblique diameter is contracted, it is due (except in some cases of
exostosis), not to compression inward of the sacro-iliac joint, but
to that of the sacral promontory or the cotyloid cavity.

46

AMERICAN ECLECTIC OBSTETRICS.

" This instrument may be employed also in measuring the pelvis
externally, but its application in this case is too simple to require
farther explanation."

The other pelvimeters, by Stein, Simeon, and Mad. Boivin, are
somewhat similar in construction to those just named, and are lia-
ble to the same objections. The pelvimeter of Stark, is rather
simple in its formation, but is decidedly objectionable, on account
of its application requiring the introduction of the whole hand
within the vagina, which would be exceedingly improper in an
unmarried female; beside which, in a small or deformed pelvis,
much pain and difficulty must necessarily attend its use.

All artificial pelvimeters are liable to more or less inaccuracy,
and in some instances are of no use at all ; still we should not omit
their employment in those cases which come before us for examina-
tion, as they will usually afford some aid toward forming a correct
diagnosis. The hand, and, under certain circumstances, the index
finger of the accoucheur, when skillfully introduced into the vagina,
is undoubtedly the most certain and accurate pelvimeter we have,
and can be employed with all females, whether married or not. I
am aware that writers generally oppose the use of the finger in the
examination of the unmarried, and would impress it upon all
practitioners as a correct rule by which to be governed, more
especially in this country, where pelvic deformities are rarely to be
met with ; but when the female has arrived at the marriageable
period, and is about to enter into wedlock, yet doubts are enter-
tained as to the perfect formation of the pelvis, and the other
indications lead us strongly to suspect some defection, we should
not hesitate a moment in performing a manual exploration, consid-
ering the future health, happiness and life of the individual of too
much importance to herself, her friends and society, to be trifled
away by an unwise regard to customs or opinions, which are
only strictly applicable to the healthy, and those of perfect con-
formation.

In the manual examination, it is preferable to have the female
standing erect, with her shoulders against the wall ; the index
finger, having been previously oiled, should then be carefully intro-
duced into the vagina, with the end of the finger pointing upward
and backward, in the direction of the promontory of the sacrum.
If, when the radial portion of the finger has reached the lower
edge of the symphysis pubis, the sacral promontory can not be felt,
we may safely determine that this diameter of the superior strait,

MALCONPORMATION OF THE PELVIS.

47

the anteroposterior, is not deformed; but if the sacral promontory
can be felt, a mark should be made upon the finger, at its point of
contact with the symphysis pubis, and then withdrawing it, the
distance between the mark and extremity of the finger will give us
the exact measurement of this diameter, if we deduct from it six
lines, for the thickness of the symphysis pubis, and two or three
lines for the obliquity of the measurement.

But this is only useful where the pelvis is much distorted, or
where the antero-posterior diameter of the brim is less than three
inches. Other methods have been advised, where greater accu-
racy is required, such as the introduction of the whole left hand
within the vagina, to such a distance that the external edge of the
little finger may be placed against the inner surface of the sym-
physis pubis, and the first finger against the
promontory of the sacrum. As the hand
must be opened, after having entered within
the vagina, the practitioner can ascertain both
the antero-posterior and transverse diame-
ters, by knowing whether the whole width

Fig. 14.

Manual Pelvimetry.

of the digital extremities of the hand can be
introduced into the space under investiga-
tion— whether he must spread his fingers to
touch the extreme limits of the diameters —
or, whether he can only introduce two or
three fingers. In the first instance, the diam-
eters will be equal to the width of the digital
extremities of the hand; in the second, they
will be more than three inches, and perhaps
four; and in the latter, the measurement will
be from one and a-half to three inches, according to the measure
of the fingers introduced. {Fig. 14.)

The distances between the ischiatic tuberosities can be ascer-
tained by moving the finger from side to side, or by means or a
pair of compasses applied externally. The finger can likewise
measure the antero-posterior diameter of the inferior strait, by
applying its radial portion to the symphysis pubis, with the extrem-
ity pointing toward the apex of the coccyx. The transverse and
oblique diameters of the superior strait may also be ascertained,
sufficiently accurate for all practical purposes, by carefully exam-
ining the circumference of the brim with the finger, in cases where
this is practicable. The length of the symphysis pubis, the curve

48 AMERICAN ECLECTIC OBSTETRICS.

\

of the sacrum, the projection of the spine of the ischium, the
shape of the straits, the condition of the lateral parietes of the
cavity, and the presence of any tumor within the pelvis, can
always be decided by the finger much better than by any instru-
ment. And in cases where the fetal head does not advance during
labor, the finger can readily determine the space existing between
the circumference of the head and that of the pelvis, and thus
instruct us whether the pelvis be sufficiently proportioned, or not.

In cases where the child's head is some-
what protruded into the pelvis, even when
the brim is contracted, and the hand can
not, in consequence, be carried up to make
an accurate examination, Ramsbotham re-
commends two fingers of the left hand to be
introduced within the vagina, the extremity
of the first finger being placed exactly be-
hind and against the symphysis pubis, and
the tip of the second against the sacral
promontory. If the examiner will then
carefully withdraw the fingers, keeping them
steady, the distance between their extremi-
ties may be measured on a scale of inches, or

otherwise, and thus e-ive the exact dimensions
.anual Pelvimetry. ' °

of the antero-posterior diameter. {Fig. 15.)

CHAPTER VI.

THE FETUS, ITS DIVISIONS AND DIMENSIONS.

In order to understand the mechanism of labor, beside having a
knowledge of the pelvis and its divisions, it is likewise necessary
to become well acquainted with the dimensions of the various
parts of the fetus, especially those which, from increase of size,
may render it difficult or even impossible for labor to progress.
Accoucheurs generally divide the fetus into three distinct parts,
namely: the head, the trunk, and the extremities; some, however,
in consequence of the peculiar manner in which it is curved upon
itself when within the uterine cavity, object to this division, and
prefer another, comprising, 1, the cephalic extremity, or head; 2, the

THE FETUS — ITS DIVISIONS, ETC.

49

pelvic extremity, including the pelvis and the inferior extremities;
and 3, the torso, or trunk, having reference to the parts between
the head and upper pelvis. But the first arrangement is sufficient
for all practical purposes.

The head is of an oval shape, and is the largest and least
reducible part of the fetus, and a familiarity with its obstetric
divisions and dimensions is highly necessary for the successful
accoucheur. The bones of the fetal cranium are the same in num-
ber as in the adult head, but they are soft, and are not united by
firm sutures as in the adult ; their imperfect ossification gives rise
to membranous spaces between them of greater or lesser extent,
called commissures or sutures, from the Latin word suo, to sew, and
which are often of much benefit to the safety of the child during
its passage through the pelvic canal, inasmuch as in every delivery
they admit a certain degree of compression or reduction of the
head, and even a riding of the bones over each other. They also
serve as indications by means of which, the position of the head in
the pelvis may be correctly ascertained. There are several of these
sutures, but those which are the most important, are three in num-
ber— the others are of no practical utility in an obstetrical point of
view.

1st. The sagittal or median suture or commissure, is situated
between the two frontal and the two parietal bones, and extends
from the root of the nose to the superior angle of the occipital bone,
dividing the anterior and superior portion of the cranium into two
equal parts ; anteriorly, it is crossed at right angles by the coronal
suture, and terminates posteriorly at the lambdoidal suture. Occa-
sionally, but very rarely, instances are found where this suture
extends throughout the occipital bone, dividing it into two parts.

2d. The coronal suture, sometimes called the transverse, anterior, or
fronto-parietal, crosses the sagittal suture at right angles, separating
the frontal from the parietal bones, and extends from the extremity
of the greater wing of the sphenoid bone of one side, to that of the
opposite side.

3d. The lambdoidal, or occipitoparietal suture, separates the upper
edge of the occipital bone from the posterior edges of the parietal
bones; in shape it resembles the Greek capital, lambda.

At the points of intersection and junction of these commissures
are membranous spaces or openings, occasioned by the incomplete-
ness of the ossification of the angles of the bones. There are six of
these spaces in the fetal head, of which a knowledge of but two is

50

AMERICAN ECLECTIC OBSTETRICS.

all that is required for practical purposes; they are technically
termed fontanelles from fons, a fountain; they have also been called
bregmas, from a Greek word signifying " to sprinkle," each name
originating from an ancient idea that a moisture passed from the
brain through these membranous spaces.

The anterior fontanelle, also called the bregmatic, or frontal, is the
opening situated at the intersection of the coronal and sagittal com-
missures ; it is of a quadrangular or diamond-shape, and may be
distinguished by the four bony angles, the edges of which are soft
and smooth, being almost always tipped with cartilage. The open-
ing is of considerable size, which, however, varies in different heads,
and the finger can readily detect it by its soft, smooth, and yield-
ing character.

The posterior or occipital fontanelle, is situated at the center or
angle of the lambdoidal commissures at its point of junction with
the posterior extremity of the sagittal commissure. In the imma-
ture fetus it may be felt distinctly, but in the full-developed infant
it consists of merely a kind of triangle formed by the meeting of
the two commissures, and is frequently wanting. This fontanelle
maybe distinguished by its triangular shape; its narrowness, being
much smaller than the anterior fontanelle; having but three bony
angles; and in consequence of the more complete ossification of
the edges of the bones, they impart to the finger, on pressure, a hard,
serrated sensation, which is never possessed by the edges of the
anterior fontanelle, and which, therefore, will enable the practitioner
to distinguish the one fontanelle from the other. Inniany»instances
the posterior fontanelle is so small that it can only be distin-
guished by the three commissure lines that radiate from a common
center.

It has been previously remarked, that occasionally the sagittal
commissure continues throughout the occipital bone, dividing it into
two parts, and in instances where this occurs, four bony angles will
be perceived by the finger. The practitioner, however, can not err
in this, if he will recollect that the posterior fontanelle is always
smaller, and its edges rougher and harder than the anterior, and
that on the slightest compression of the head, the occipital bone
always glides under the ossa parietalia. The anterior fontanelle is
invariably larger than the posterior, no matter how well marked
this last may be.

A thorough knowledge of the sutures and fontanelles is absolutely
required in the practice of midwifery — for it is from them that the

THE FETUS — ITS DIVISIONS, ETC.

51

position of the head within the pelvis is ascertained with certainty;
and in cases where interference is demanded, from a too early
departure of the head from its proper or flexed position, or from
some other cause, the educated accoucheur can at once render the
necessary assistance to bring the labor to a safe and prosperous
termination. But if he have neglected to inform himself on these
points, his patient may be subjected to much unnecessary suffering,
and, perhaps, from lack of timely aid, the death of both mother and
child may ultimately ensue. Hence, a perfect acquaintance with
these peculiar marks can not be too strongly impressed on the mind
of the student. It is from these alone, that the situation of the
head when in the pelvis can be correctly ascertained, and never by
an ear, nose, or other part of the head.

There are four principal DIAMETERS belonging to the fetal
head, viz : —

1. The large, oblique, or occipito -mental diameter (a B,Fig. 16), ex-
tending from the vertex or posterior fontanelle to the symphysis of the
chin; its measurement is from five to five FTa T6
and a half iuches. Is is important to rec-
ollect this diameter, for if it enters the
cavity with either extremity descending^
it can not be reversed, from want of space,
but must either be allowed to escape as
it presents, or be returned above the su-
perior strait to effect a change. This
diameter may be safely elongated by com-
pression of the cranium with the forceps Diameters of the Fetal Head.

, i • ,i , , n i A. B. Occipito-mental.

or otherwise, to the extent of six or ten b e. occipitofrontal,
lines, so that its whole measurement may c H- cervico-bregmatic.

. . I G. Trachelo-bregmatic, or vertical,

be SIX 01* Seven inches. A D. Fronto-mental, or facial.

2. The longitudinal, horizontal, antero-posterior or occipitofrontal
diameter (d e, Fig. 16), extends from the center of the forehead to
the occipital protuberance ; its measurement is from four, to four
and three-quarter inches.

3. The perpendicular, vertical, occipito-bregmatic or trachelo-breg-
matic diameter (g i, Fig. 16). extends perpendicularly from the
most elevated point of the vertex, or top of the head to the ante-
rior portion of the great occipital foramen ; its measurement is
from three and a half to three and three-quarter inches.

52

AMERICAN ECLECTIC OBSTETRICS.

4. The small, transverse, or bi-parietal diameter (a. b, Fig. 17),
extends from the center of one parietal protuberance to that of the
other; its measurement is from three and a half to nearly four
inches. This diameter may, by compression of the cranium with
the forceps or otherwise, be diminished one-third or even three-
fourths of an inch, without any injury to the child.

In addition to these measurements of the fetal head, with which
the student must become familiar, authors have given several
others, a knowledge of which, however, is not necessarily import-
ant in practice ; they are :

1. The cervico-bregmatic diameter (c h, Fig. 16), which extends
from the back part of the neck to the center of the anterior
fontanelle ; it measures from three and a half to three and three-
quarter inches.

2. The fronto-mental, or facial diameter (a d, Fig. 16), extends
from the symphysis of the chin, to the center of the forehead ; it
measures from three to four inches.

3. The -post trachelo-frontal diameter, which extends from a point
midway between the occipital protuberance and the occipital
foramen, to the center of the frontal bone ; it measures from four
to four and three-quarter inches.

4. The prce-trachelo occipital diameter, extends from the hyoid
bone to the posterior fontanelle ; it measures from three and a
half to four inches.

5. The bi-temporal diameter (c r>, Fig. 17), extends from the root
of the zygomatic process on one side to the same point oppo-
site ; it measures from two and three-quarters to three inches.

6. The sub-occipito bregmatic diameter, extends from a point mid-
way between the foramen magnum and the occipital protuberance
to the anterior fontanelle; it measures three and three-quarter
inches.

In order that the diameters of the fetal head may, at one glance,
be compared with those of the pelvis, I present the following
tables after the manner of Cazeaux :

Diameters of the pelvis
(in inches.)

Superior Strait.
Inferior Strait...
Excavation

Antero-posterior

.4 to4J...
.4 to 5 ...
.4| to 51

Transverse.

.5 to5J...
.4 to 4J...
A\ to 4f.

Oblique.

.41 to 5.
.4 to4J.
■4|

Sacro-cotyloid.

.3| to 4£...

THE FETUS — ITS DIVISIONS, ETC.

53

Diameters of the Fetal Head.

Longitudinal Diameters.

Transverse diameters

Vertical diameters

C Occipito-mental 5 to 5.} inches.

a Occipitofrontal 4 to 4f "

(_ Sub-occipito-bregmatic 3£ "

Bi-parietal 3i to 3f "

Bi-temporal 3 "

f Trachelo-bregmatic 3£ to 3f "

( Fronto-mental 3 to 4 "

A comparison of the diameters of the fetus with those of the
pelvis, will be found of much utility, enabling the practitioner
more readily to effect a correspondence between the large diame-
ters of the head and the long diameters or axes of the pelvis, in
all cases where such a change may be required. From an investi-
gation of these measurements, it will be seen that at full term, the
fetus, to be safely and readily expelled must present one end of its
long diameter (a or b, Fig. 16); and also, that if its occipito-men-
tal diameter is parallel with the plane of the inferior strait,
delivery will be impossible; either the chin or the occiput must
descend first. It will likewise be observed, that the most favora-
ble position for the expulsion of the fetal head, is to have it
strongly flexed upon the body, so that its largest diameter, the
occipito-mental, shall correspond to the long diameters or axes
respectively of the straits and cavity, whHe its sub-occipito-breg-
matic diameter, shall be parallel to the plane of the straits, and the
occiput shall, during its passage, correspond to
one extremity of an oblique diameter, until the
rotation ensues which places the presenting ex-
tremity under the arch of the pubis.

Each of the diameters of the fetal head have a
circumference assigned to them, the largest of
which is the occipito-mental circumference, and
which with the occipito frontal or horizontal cir-
cumference, are more important than the others,
because, during labor, they successively come into Diameters of
relation with the pelvic parietes. The fronto- Fetal Head.
mental circumference, passes over the chin, cheeks a b. Bi-ranetai.
and forehead, and is consequently termed by c f. Bi-tomporai.
several writers, the facial circumference. The remaining circum-
ferences are unimportant.

Fig. 17.

54

AMERICAN ECLECTIC OBSTETRICS.

The other diameters of the fetus are :

1. The bis-acromial diameter, extending from one acrimonial
process to the other; it measures four and a half inches.

2. The dorso-siernal diameter, extending from the vertebral col-
umn through to the sternum; it measures three and a half inches.

3. The bis-iliac diameter, extending from the crest of one
ilium to that of the other ; it measures three and three-quarter
inches.

4. The bi-trochanteric diameter, extending from one trochanter to
the other; it measures three and a half inches.

The movements which the fetal head is enabled to execute with
safety, in consequence of the laxity of the articular ligaments
between the head and vertebral column, must not be forgotten. In
head presentations, the shoulders are usually expelled so soon after
the head has passed, that accidents are rarely met with ; but in
breech or feet presentations, or in cases of turning, in which the
head may be retained -for some time within the cavity from mal-po-
sition or otherwise, the careless or unskilled accoucheur may, by
the employment of an ill directed force, occasion the death of the
child.

The head may be moved in four different directions, termed
flexion, extension, lateral inclination and rotation; and the extent to
which these movements may be carried, must never be lost sight of.

The movement of flexion, is that in which the head is thrown for-
ward and downward, so that the chin is depressed upon the neck or
upper part of the sternum, and to which extent this motion is lim-
ited. By it, the occipito-mental diameter of the head is made part
of the long diameter of the fetal ovoid or ellipse. This movement
of the head should never be forgotten, as when it is incomplete, or
there is too early a departure of the chin from the breast, during
the passage of the head through the pelvic canal, an attention to it,
with the proper manipulation to restore the flexion, as hereafter
described, will very much facilitate the expulsive progress of the
head; but a want of care or knowledge in this matter may, in these
instances, render the labor tedious, painful and even hazardous.

The movement of extension, is the reverse of the former ; the head
is thrown backward; and the motion is limited by the occiput
coming in contact with the back of the neck. This motion takes
place in occipito-anterior positions of the head, in which the vertex
becomes placed under the pubic arch, while the forehead, face and

THE FEMALE ORGANS OF GENERATION.

55

chin, leaving their previous state of flexion, pass successively along
the arch of the sacrum, coccyx and perineum.
^ The movement of lateral inclination is that in which the head is
thrown to one side or the other, and is limited hy the side of the
head, meeting with the corresponding shoulder.

The movement of rotation, is that in which the face of the child is
turned from one side to the other. All the other motions are limited
in their extent by an opposing obstacle, but in this last there is none
presented, and if it be carried too far the life of the child will be
endangered. I have met with several cases of still-born infants,
occasioned by the midwife rotating the body of the child beyond
its proper limits ; and instances are recorded where the body has
been made to turn once and even twice, almost, if not actually
twisting off the neck. It must be borne in mind that the head can
not be rotated upon the neck, with [safety, beyond one quarter of a
circle, or in other words, the face of the child can not be turned to
the right or left beyond the corresponding shoulder; and this
applies to the head when out of the pelvis, and the body within, and
likewise to the body out of the pelvis and the head detained.

One thing may be adverted to here which will be again noticed
in another place, and which is, that pulling the body of the child
for the purpose of extracting the head, or pulling with the forceps
applied to the head, the body not being expelled, are not only
improper but exceedingly culpable. I have known a practitioner,
in his endeavor to extract the head with the forceps, pull so forci-
bly and continuously, as to almost tear the head from the body, at
the same time lacerating the soft parts of the mother in a most
shocking manner.

CHAPTER VII.

THE FEMALE ORGANS OF GENERATION.

Having referred to the osseous portions of the female and of the
fetus, in their obstetrical relations, it becomes necessary to briefly
notice the soft parts which cover them, constituting in the adult
female, the organs of generation, and which are divided into
external and internal. The external organs, to which the term Puden-
dum is applied, are situated on the exterior of the pelvis, where
they may be noticed by the eye, and comprise, 1st. The mons

56

AMERICAN ECLECTIC OBSTETRICS.

Fjg. 18.

veneris; 2d. The vulva and
its parts; 3d. The perineum.
The internal organs are
more deeply seated, and can
not be seen or studied ex-
cept by dissection ; they
are, 1st. The vagina; 2d.
The uterus; 3d. The fallo-
pian tubes and ligaments;
and 4th. The ovaries.

The MOm VENERIS,
or supra-pubal eminence, is
a triangular space situated
at the lower part of the
hypogastrium, immediate-
ly on the fore part of the
pubis, in front of, and just
above the symphysis pubis.
It presents a prominent ro-
tundity, which varies ac-
cording to the quantity of
adipose matter deposited,
and of which it is princi-

The External Female Organs of Generation.

A. The Mods Veneris.

B. The Labia Externa, or Labia Pudemli.

C. The Fourchette, or Posterior Commissure of the Vulva.
D D. The Perineum, extending from the Posterior Commis- pally COmpOSed ; it is HlOre

sure of the Vulva to the Anus.

E. The Anus.

F. The Clitoris.

G. The Preputium Clitoridis.
if. The NymphiP, or Labia Interna.
I. The Vestibulum.
K. The Meatus Urinarius.
L. The Hymen.

the natives of tropical climates,
this part is smooth in early

prominent in young and
vigorous virgins than in
mothers and aged females,
and is said to be much
more so in young females
The cutis or skin which covers
life, but becomes covered with
hair or capilli at maturity, and is supplied with numerous seba-
ceous follicles. Through the adipose cellular tissue, are ramifications
of some branches of the external pudic vessels and nerves, and in it
are distributed some fibers of the round ligaments of the uterus.

The uses of the mons veneris during copulation are not satisfac-
torily ascertained, though it is said to be more elevated when the
female is laboring under sexual excitement, and immediately pre-
vious to menstruation. Moreau states, that in parturition, owing
to the extensibility of the skin, and laxity of the cellular tissue

THE FEMALE ORGANS OF GENERATION.

57

contained within it, it assists in augmenting the size of the vulva.
This part is sometimes attacked with inflammations and abscesses
which prove exceedingly painful, and may suffer from the various
forms of disease common to the tissues entering into its formation.

The VULVA is the slit, or longitudinal fissure (fissura vulvce,
or genital fissure), which extends from the mons veneris superiorly,
along the median line, to the perineum inferiorly. The orifice of
the vulva serves as an entrance to some of the internal organs;
it varies in extent in different persons ; is very small in infancy,
small and narrow in girls, of greater width and extent in women,
and during parturition distends to a size which admits of the free
passage of the child through it. After copulation its size is usually
doable that of the vaginal orifice; and in women who have borne
many children, or who have had laceration of the perineum, it
most commonly remains quite large.

Along the lateral portions of the vulva are two rounded folds,
or oblong eminences, or lips, which extend in a longitudinal direc-
tion from the mons veneris to the posterior part of the vulva;
these are called the LABIA MAJORA, labia externa* or labia
pudendi. As they proceed from before backward, they diminish
in thickness, which renders them more prominent above than
below; their superior extremity is adherent, the inferior being free
and rounded. Externally, the labia majora are covered with the
common skin, on which a few hairs may be found, and which is
supplied with numerous sebaceous follicles; internally, it is cov-
ered with a beautifully fine, smooth, and sensitive mucous mem-
brane, of a florid color in young persons, but which is lost on the
approach of age. The inner, or mucous surface, is supplied with
glands that secrete a fluid preventing an adhesion of these parts,
as well as protecting them from the effects of friction. By their
approximation, the labia majora cover and protect the internal
parts from the air and external agencies; and during parturition,
when the child is about to be expelled, by their elongation and
almost entire disappearance, they increase the capaciousness of the
vulva. They may be attacked with inflammation, abscess, hernia,
serous infiltration, or other diseases, which sometimes interfere
with their functional activity, or occasion various accidents.

The point of union of the labia majora, at their upper, or ante-
rior extremity, at the symphysis pubis, forms the anterior commis-
sure of the vulva ; and at their lower or posterior extremity, they
5

58

AMERICAN ECLECTIC OBSTETRICS.

form a kind of bridle at the anterior edge of the perineum, called
the EOITRCHETTE, fraznum, or posterior commissure of the vulva,
which is sometimes slightly lacerated during first labors, but which
occurrence causes no trouble. The posterior commissure is the
most dense and resisting point of the vulva, not yielding without
difficulty.

On separating the labia majora, we observe several other parts ;
the NYMPH^E, labia interna, or labia minora, which are two mem-
branous folds, located between, and running parallel with, the labia
majora, and which extend from the anterior commissure to about
the center of the genital fissure; they are formed of cellular, as well
as spongy, erectile tissue, covered with mucous membrane, and con-
tain vessels and nerves which render them highly sensitive. Their
superior edge is coherent, the inferior, loose; and a little below the
anterior commissure of the vulva they unite, the anterior extrem-
ity passing around the clitoris, so as to form a hood, or prepuce to
it, while the posterior is lost in the corresponding labium pudendi.
In young persons their color is lively red, they are firm, and their
surface is not corrugated, but smooth ; in women who have had
children they become darker and wrinkled. Females of a phleg-
matic temperament, and especially those laboring under leucor-
rhea, have them pale and flaccid ; and in brunettes they are dark,
granulated, and sometimes quite long. They are furnished with a
sebaceous substance, which, if allowed to accumulate in quantity,
occasions a disagreeable fetor.

In early life the nymphse are so long as to project beyond the
external lips, or labia majora, which, however, usually disappears
at puberty. Occasionally the labia minora have projected so far
as to produce much inconvenience, requiring an operation for
their removal; and among the South Africans, especially the
Bochisman women, this elongation is found in an excessive degree,
extending to eight or ten inches below the margin of the labia,
forming what has been named the apron of the Hottentots.

The uses of the nymph.88 are unknown, although they are sup-
posed to add to the voluptuousness of copulation, and to amplify
the vulva during parturition, by becoming distended or effaced ;
this last view, however, does not agree with my own observations,
as I have repeatedly ascertained their presence during the passage
of the fetal head into the world.

The CLITORIS is situated at the superior and median part of
the vulva, at the junction or origin of the labia minora, and below

THE FEMALE ORGANS OF GENERATION. 59

the anterior commissure of the vulva. It is a small red projection,
bearing some resemblance to the male penis, having two corpora
cavernosa, which are attached to the crura of the pubes, a spongy,
cellular tissue, somewhat similar to the corpus spongiosum in the
male, two erector muscles, rendering it erectile, and is surrounded
with a fold of the internal mucous membrane of the labia, which
forms the prepuce, or preputium clitoridis. It is, however, imper-
forate, being without a canal, or urethra. At its external termina-
tion is a round, red protuberance, which, from its shape, has received
the name of glans clitoridis.

The clitoris is supplied with arteries and veins from several
sources, and its nerves, which arise from the sacri, endow it with
intense erotic sensibility. Its length is variable, and when uncom-
monly long or hypertrophied, has sometimes occasioned doubts as
to the' sex of the individual. It is of no service in parturition, but
is considered as the principal seat of venereal pleasure in the
female ; the excision of this organ in the adult female very much
lessens the voluptuousness of sexual congress; and its titillation
alone will give completion to the venereal orgasm, as in instances
of masturbation. In infants, this organ presents an apparent
excess of size, projecting beyond the vulva, and which is owing to
the want of development of the proximate organs, especially of
the labia majora.

The VESTIBULUM is a triangular space or depression, about
an inch in length, having the clitoris above, the meatus urinarius
or orifice of the urethra below, and the nymphse laterally. The
lower or inferior portion of this depression is divided by a line or
raphe, which can be readily felt with the point of the finger, and
which leads directly to the orifice of the urethra. It is supplied
with numerous mucous glands. Immediately beneath the vestibu-
lum may be recognized, situated on a line with the top of the pubic
arch, a small bulbous projection or cushion, which incloses the
orifice of the urethra. A knowledge of this arrangement will
render the catheterism of the female an easy operation.

The FEMALE URETHRA is a slightly curved canal, from one
to two inches in length. It is larger and more dilatable than that;
of the male, and passes directly beneath and behind the sym-
physis pubis in an oblique direction, upward and backward, having
its concavity upward, on the pubic side, and its convexity down-
ward, on the vaginal side. During labor or parturition, the urethra
becomes elongated, and its direction, as well as that of its orifice,

GO

AMERICAN ECLECTIC OBSTETRICS.

changes, so as to create difficulty in the introduction of the cathe-
ter. For instance, distension of the bladder with urine, distension
of the vagina by the presenting parts, or the elevation of the
uterus, may carry the urethral canal high upward, and sometimes
thrust it against the pubes, so that its orifice will be brought behind
the symphysis pubis ; in such cases, the sound or catheter must be
introduced behind and parallel to the symphysis. The urethra is
lined internally with mucous membrane, the folds of which usually
run longitudinally and not transverse.

The external orifice of the urethra, called the meatus urinarius,
is situated below the vestibulum, a*nd immediately above the
vaginal opening; it is irregularly round, and is more constricted
than the upper portion of the urethral canal. A membranous
swelling or cushion, abundantly supplied with numerous follicles,
surrounds it; and in ordinary cases, where the introduction of the
catheter is necessary, after having found this raised cushion, which,
as already stated, is at the lower part of the vestibulum, directly
under the symphysis pubis, the orifice will be discovered in the
center of it. The point of the catheter should be directed perpen-
dicularly to the surface of the vestibulum, introduced within the
orifice, then by depressing the handle, the point will turn upward
behind the pubis and toward the bladder. This tubercle or
caruncle of the urethra varies in its development, the orifice being
sometimes very thin, merely membranous, and at others very patu-
lous and funnel shaped.

In instances where from long-continued pressure of the child's
head, or from other causes, the practitioner is unable to detect the
meatus urinarius, and it is absolutely necessary that the bladder
should be evacuated to avoid its rupturing, or the probable forma-
tion of a fistulous passage between it and the vagina, it may be
necessary for the practitioner to expose the parts to sight, in order
to introduce the catheter, indeed, it is his duty to do so; but under
ordinary circumstances the patient should never be exposed for the
operation.

The urethra may be so severely pressed by the fetal head as to
occasion sloughing, resulting in urethro-vaginal fistula, which is a
very difficult malady to remove; and in operations with the for-
ceps or crotchet, the practitioner should be extremely cautious not
to bruise or lacerate this canal, as it is almost certain to result in
permanent stillicidium of urine. The urethral mucous membrane is
subject to prolapsus, tumefaction, and occasionally polypus growths.

THE FEMALE ORGANS OF GENERATION.

61

The HYMEN, also termed the virginal valve, vaginal valve, fios
virginitatis, claustrum virginale, etc., is a membranous fold formed
by the mucous membrane of the genital surface. It is situated
about half an inch within the vulva, at the orifice of the vagina,
which it closes more or less perfectly, and is usually in the shape
of a crescent, with its convexity downward and adhering, and its
concavity upward and detached. Sometimes it is oval from right
to left, or circular, with one or more openings which allow the
various secretions and discharges from the vagina and uterus to
pass out; occasionally, it is imperforate, preventing the egress of
th ese discharges. Ordinarily, the hymen is quite thin and delicate,
being ruptured by the slightest causes; sometimes it is soft and
lax, yielding without rupturing; and instances have occurred in
which it was so firm as to present an obstacle to copulation, or to
embarass the process of parturition, to remedy which, it has been
found necessary to make a circular incision in it.

The uses of this membrane are not well defined, nor can they be
of much consequence, since it is lost daily without injury. The
presence of the hymen has long been regarded as a sign of vir-
ginity, but when we reflect that it is sometimes readily ruptured in
females of undoubted chastity, even in the acts of laughing, cough-
ing, sneezing, lifting, etc., and again that it has been found entire
at the time of parturition, most convincing proof is afforded, that,
as an emblem of virginity, this membrane can not be depended
upon under any circumstances whatever; for its absence affords no
evidence that sexual intercourse has taken place, nor does its pres-
ence prove the condition of chastity. It is often destroyed, during
infancy, by careless nurses who rub these parts roughly with a
coarse towel. I have met with three instances only, of firm and
imperforate hymen in which it was impossible for the nuptial rites
to be consummated, and one in which it was present at the parturi-
ent period, and in each of which the difficulty was removed by the
bistoury.

Along the circumference of the orifice of the vagina, are several
small, flat, or rounded reddish tubercles, commonly numbering from
two to four, occasionally five or six Sometimes they are pale, or livid,
and vary in firmness. They exist in pairs, the two posterior being
generally larger and longer than the anterior. These are termed
the CARUNCITL^E MYRTIFORMES, and are considered by some
anatomists as the remains of the ruptured hymen, while others view
them as existing independent of this membrane. I have, in three

62

AMERICAN ECLECTIC OBSTETRICS.

instances, witnessed the unruptured hymen simultaneously with the
presence of the camnculse. As they disappear during the expulsion
of the fetus, they may probably be designed for enlarging the ca-
pacity of the vulva, thereby diminishing the risk of severe contusion
or laceration. When they become so large as to cause unpleasant
symptoms they may be removed by the scissors.

Between the posterior commissure of the vulva, or fourchette,
and the hymen and the external orifice of the vagina, is a space or
depression bearing some resemblance to the cavity of a small boat,
which is called the FOSSA NAVICULARS, or concha. Its
greatest extent is six lines, or half an inch. It is found in girls
and in women who have not given birth to children, but is usually
ruptured in a first confinement by the efforts made to expel the
fetal head, and which is followed by no serious consequences unless
more or less of the perineum be likewise involved. It is the most
inferior part of the vulva, and hence becomes a receptacle for
vaginal and uterine discharges; and inflammation and syphilitic
ulcerations are frequently located there, among public women,
which occasion obstinate and incurable difficulties.

The PERINEUM proper, includes the whole of the space
between the coccyx and the pubes, including the terminal orifices
of the urinary, generative, and digestive apparatus; but in Obstet-
rics, by the term perineum, is meant the space lying between the
posterior commissure of the vulva and the anus. It is from an
inch to an inch and a half in length, and presents on its external
surface, on the mesial line, a prominent, hard ridge, which is
termed the raphe of the perineum. Externally the perineum is
covered with the skin; internally, it consists of adipose cellular
tissue, of fascia, and of several muscles. In some females it is
thick, hard and resisting; in others it is thin, soft, and easily
dilated; conditions which render labor tedious or otherwise, by
retarding the passage of the fetal head when rigid and unyielding,
or allowing it to pass by a ready dilatation.

In the last stage of labor, the perineum usually offers more or
less resistance, but eventually becomes thinner, elongates, and
extends, even to four or five inches, thus affording a passage for
the child ; and it is at this period, when the head is passing, that
it becomes occasionally lacerated, or more rarely, perforated
through its center. This accident, however, may generally be
avoided, by supporting the perineum with the hand, making such

INTERNAL ORGANS OF GENERATION.

63

firm but moderate pressure as will prevent the head from advanc-
ing too rapidly, and which, at the same time, will allow the tissues
an opportunity to acquire the proper degree of extensibility.
Excessive and injudicious support will undoubtedly effect more
mischief than benefit. The condition of the perineum should never
be overlooked by the practitioner, as it frequently presents an
obstacle to delivery far greater than the os uteri, the straits, and
the vagina together, owing to its unyielding resistance; and a labor
which, under ordinary circumstances, would be finished in from
fifteen to thirty minutes after the head has reached this point, may
be continued for several hours. This rigid condition of the per-
ineum is often brought on by excessive meddling, frequent exam-
inations, etc. I have overcome several instances of obstinate
resistance, in a very short time, by the application to the perineum
of a warm poultice composed of Hops, Lobelia leaves, Water and
soft Soap; other applications of a similar nature may answer, but
they must only be employed in those cases where the perineum
does not appear to yield in the least degree {Fig. 18).

CHAPTER VIII.

THE INTERNAL ORGANS OF GENERATION.

The internal organs of generation, belonging to the female, are,
as previously remarked, the vagina, the uterus and its appendages,
the Fallopian tubes, ligaments, and ovaries {Fig. 19).

The VAGINA, is a cylindrical membranous canal, which con-
nects the internal with the external organs of generation ; it is
located in the pelvic cavity, being posterior to the bladder and
urethra, and anterior to the rectum. Its direction is nearly coinci-
dent with the axis of the pelvis, which gives a curved form to it, the
concavity of which, is on its anterior or pubic surface, and the con-
vexity on its posterior or rectal surface. The walls of the vagina
are soft and yielding, and slightly flattened from before backward —
the anterior wall being shorter than the posterior. In well formed
women, its length is five or six inches, and its width one, but this
usually varies according to age, and the different circumstances of
life. In girls, it is longer and narrower than in married women,

64

AMERICAN ECLECTIC OBSTETRICS.

Fig. 11

and especially those who have
borne children ; and in African
women it is longer and wider
than in European. The middle
portion of the vaginal tube is
larger than at the extremities,
and the lower or inferior orifice
is more contracted than at its up-
per or superior extremity. As
females advance in years, the
vagina gradually contracts its
dimensions to nearly those found
in young girls. It is composed
of a fibrous and mucous mem-
brane ; the first is placed exter-
nally, and consists of condensed
cellular tissue, highly elastic, and
of a reddish color.

The external surface of the vagina
is united, in front to the bas-fond
of the bladder and to the urethra,
by cellular tissue, which becomes
denser as it approaches the'vulva;
behind, to the rectum, by similar
cellular tissue, but which is less dense than in front; laterally, to the
broad ligaments and ureters above, and below to the umbilical arte-
ries, the sacral plexuses, the hypogastric vessels, the levator muscles
of the anus, and the pelvic cellular tissue; and superiorly, above
and behind, by a double fold of peritoneum.

The internal surface of the vagina is divided into an anterior and a
posterior wall. In the center ot each of these parietes is a longitu-
dinal line or ridge, the one on the anterior being more distinct and
prominent than that on the posterior wall ; these ridges are called
column ce vagina:, or columns of the vagina— one, the anterior column
of the vagina, the other, the posterior column of the vagina. One
or two tubercles are generally found at their inferior terminations.
These columns are intersected at right angles by transverse par-
allel rugse, folds or wrinkles, which become more prominent and
approximate more closely as they advance toward the vulva; these
rugse, however, do not constantly exist; they are more distinctly
marked in girls and in aged women; and during pregnancy, as well

The Internal Female Genital Organs.

A. The Uterus, seen on its Anterior Face.

B. The Intra-vaginal portion of the Neck of the

Uterus.
C C. The Fallopian TuVs.

D. The fimbriated Extremities of the Fallopian
Tubes.

E E. The Ovaries.

F. The Ligament of the O- ary.

G G. The round Ligaments.

H. The Vagina laid open.

On the right the fimbriated extremity of the Fal-
lopian Tube is seen applied to the Ovary.

INTERNAL ORGANS OF GENERATION.

65

as for a short period after parturition, they are nearly effaced. Some
writers consider them as aids to the enlargement of the vagina dur-
ing labor ; others, that they assist in the elongation which it under-
goes during pregnancy, caused by the ascent of the uterus : and
others again, that by multiplying the points of contact between them
and the male organs, the voluptuousness of coition is increased.

Th$ superior, internal, or upper extremity of the vagina, is attached
around the upper part of the neck of the uterus, being a little higher
behind than in front. The peculiar manner by which it embraces
the neck, gives rise to a circular fissure or groove, to which the name
cul-de-sac has been applied; the one in front, being termed the ante-
rior cul-de-sac; that behind, and which is more distinctly marked, the
posterior cul-de-sac. These culs-de-sac are of greater or less depth,
according to the projection of the neck of the uterus. This portion
of the vagina is in immediate contact with the peritoneum, which
separates it from the abdominal cavity; and it is here where injuries
are most commonly inflicted by the use of instruments, often
resulting in inflammation and death ; hence, when operations are
demanded, great care should be observed by the operator.

The inferior, external, or lower extremity of the vagina, sometimes
termed the external or vulvar orifice, which terminates below the
urethra, is narrowed at its entrance, and, in the virgin, is usually
partially closed by the hymen.

The internal parietes of the vagina are composed of a mucous mem-
brane which is the continuation of that of the vulva, and internal
membrane of the uterus ; inferiorly, this membrane is of a red or
Vermillion tinge, and superiorly it has a whitish or grayish appear-
ance. Occasionally, it presents posteriorly, bluish or livid spots,
which are more or less irregular. It is furnished with numerous
mucous follicles, the secretions from which constantly keep the
parts during health, and especially during parturition, in a state of
lubricity. If this organ becomes dry and inflamed, while labor is
progressing, a rigid and unyielding condition of it ensues, which
must necessarily occasion much distress to the patient; hence the
importance of examining during labor, as seldom as possible,
because the frequent introduction of the finger into the vagina not
only removes the moisture of the parts, but likewise irritates them ;
beside frequent touchings are useless, deleterious and immodest.

The part surrounding the orifice of the vagina, is termed the bulb
of the vagina or the plexus retiformis; it is a dense, compact, erectile
spongy tissue, somewhat resembling that of the corpus spongiosum

66

AMERICAN ECLECTIC OBSTETRICS.

urethrse, of a grayish or bluish color, about an inch in breadth, and
|wo or three lines in thickness. During the venereal orgasm, it
contracts the vaginal cavity, and thus increases its resistance. The
sphincter vagina or constrictor vagince muscle is formed by some mus-
cular fibers on the outside of this spongy tissue ; it contracts the
vaginal orifice, and depresses the clitoris.

The arteries of the vagina come from the internal iliac ; its veins,
which are numerous, form a kind of net-work called plexiform, and
flow into the hypogastrics ; its nerves arise from the sacral plexus,
and its lymphatics are lost in the hypogastric lymphatic plexus.
The contractility of the vagina is of the peculiar elastic character
common to all cellular structure. As soon as the fetus has been
expelled, this organ resumes its natural condition in a very short
time, except in cases where the head has been confined in the cavity
for a longer period than usual, when its contraction will hot take
place for one or two hours; and the hand may be very readily
introduced within it for some hours after delivery.

The vagina serves as a medium through which external bodies may
pass toward the uterus, as during copulation, and also through
which the uterine contents and vaginal secretions may pass off, as the
fetus, menses, etc. It is subject to inflammation, ulceration, eversion,
inversion, etc., the history and treatment of which, more properly
belong to a treatise on " Diseases of Women."

The UTERUS, or womb is a hollow organ, whose principal func-
tions are to receive the impregnated ovum, as it escapes from the
Fallopian tube, to assist in its nourishment, growth, and preserva-
tion, until the parturient period arrives, and then to act as the prin-
cipal agent in forwarding its expulsion. It is a gestative, not a genera-
tive organ.

In shape, the uterus is conical or pyriform, usually described as
resembling a pear flattened from before backward, with its base
turned upward, and its apex downward. It is situated obliquely in
the pelvic cavity, below the small intestines, between the bladder
and rectum, and above the vagina; and is retained in its position
by the round and broad ligaments, and the vagina. Its axis or long
diameter very nearly corresponds with the axis of the superior strait.
In very young females its base is below the superior strait ; in
adults it is nearly on a level with it.

In childhood it is quite small, but rapidly increases in growth
toward puberty and adult age, and after the period of child-bearing,

INTERNAL ORGANS OF GENERATION.

67

it diminishes to nearly its infantile size. Its average length, in the
adult woman, is three inches ; its breadth at the fundus, two inches,
and toward the neck, including the os tincse, one inch to one and a
half inches; and its thickness from eight to twelve lines, or from
four to six lines for each of its walls.

Immediately previous to menstruation and during that term, it
usually becomes greatly augmented in volume, which may be mis-
taken for the commencement of a pregnancy. Its weight, in the
virgin female, is seven or eight drachms, and in those who have had
children, from twelve drachms to an ounce and a half, while in the
aged female it dwindles to one or two drachms.

The uterus is divided into three parts: 1, the base or fundus uteri,
which is only a few lines high, being confined to all that portion
which rises above the insertion of the Fallopian tubes; 2, the body or
corpus uteri, which is the largest division of the uterus, and includes
all that part of the organ situated T)etween the fundus and the neck,
or contracted portion : 3, the neck or cervix uteri, which is the con-
tracted and elongated portion found below the body, and which is
embraced by the vagina, forming in its cavity a projection of four to
six lines, at the extremity of which is an opening, termed os tincce,
from its fancied resemblance to the mouth of the tench fish.

Generally, the uterus is slightly inclined to the right, sometimes
to the left, or backward. Its position, however, is not constant,
being determined by its own condition, as well as that of the neigh-
boring parts. Thus females in whom the vagina is short, will have
the axis of the uterus approximating that of the inferior strait; some-
times the fundus is thrown so far forward that the anterior wall is
the most inferior part, constituting an anteversion ; at other times it
may be the reverse of this, the fundus being thrown in the
hollow of the sacrum, and the neck behind the symphysis pubis,
producing a retroversion; or, the fundus may be thrown to one side
of the pelvic cavity, with the neck to the opposite side, which is
termed lateral version ; and again, the body of the uterus may be
bent on the neck, either behind or in front, constituting an anteflexion
or retroflexion.

We distinguish, in the uterus, an external and an internal surface.
The EXTERNAL SURFACE is divided into an anterior and a
posterior face, a superior and two lateral borders, two superior angles,
and an apex.

The anterior face is smooth, polished, slightly convex, covered on
its superior two-thirds by a prolongation of the peritoneum, and is

68

AMERICAN ECLECTIC OBSTETRICS.

in contact with the posterior face of the bladder, from which it is
sometimes separated by some folds of the small intestine; inferiorly,
it is united to the bas-fond of the bladder by loose cellular tissue,
and which adhesion may account for the involvement of the bladder
in many uterine displacements.

The posterior face is more convex than the anterior, and is covered
throughout its whole extent by a prolongation of the peritoneum,
it is likewise in contact with the anterior surface of the rectum
looking toward the concavity of the sacrum. The superior border,
base or fundus, is convex, looking upward and forward, and is cov-
ered in its whole extent by a prolongation of the peritoneum, and
by the convolutions of the small intestines. In the unimpregnated
state it never reaches the level of the superior strait, and can not,
therefore, be felt through the inferior abdominal wall, except by
making considerable pressure. The two lateral borders are irregular,
being convex in their superior half, and concave in their inferior;
they are situated between 'the two duplicatures of the peritoneum;
which constitute the broad and round ligaments, and which liga,
ments being attached to the anterior edge of the lateral borders, are
consequently on the same plane as the anterior face of the uterus. The
two superior angles, or cornua uteri, are formed at the junction of the
superior with the two lateral borders, and from which point arise
the Fallopian tubes and ovarian ligaments; the apex is the inferior
extremity of the uterine neck, and is situated in the upper part of
the vagina.

The CERVIX UTERI, or NECK OF THE UTERUS, should
be thoroughly studied by the practitioner, with regard to its form,
size, and consistence, in order to facilitate his diagnosticating the
state of pregnancy, full term, etc., as well as the many abnormal
conditions to which it is liable.

The neck of the uterus in the adult female who has never borne
children, will be found to vary considerably from that of one who
has; it is from twelve to fifteen lines in length, cylindrical, flattened
from before backward, and fusiform, being about nine lines in its
transverse diameter at the center, and from four to six lines at its
extremities. It is embraced by the vagina toward its upper portion,
leaving about two-thirds within the vagina, and one-third above
the vaginal adhesion. The inferior or vaginal extremity of the
neck, is of less volume than any other part of it, and is perforated
in its center by a transverse fissure or orifice, of one or two lines in
length, to which several names have been applied, as, os tincce, os

INTERNAL ORGANS OF GENERATION.

69

uteri, os internum, mouth of the womb, uterine orifice, etc. In the
virgin, this orifice is completely closed up, and is sometimes difficult
to find ; the sensation conveyed to the finger in contact with it, is
similar to that experienced by feeling the depression between the
alse nasi, at the end of the nose, with the pulp of the finger, and
which sensation will assist us in recognizing the opening. The os
tincse divides the apex into two lips, an anterior and a posterior lip.
These lips are smooth, regular, small, firm, thin, and closely approx-
imated, the one anterior being slightly thicker and more prominent
than the posterior. As the long diameter of the uterus is nearly
parallel with the diameter of the superior strait, the face of the
apex will be found looking toward the lower portion of the sacrum,
in an inclined positiou ; from which arrangement the anterior lip
will be found a little lower down than the posterior.

In the woman who has borne children, the uterine neck varies in
its extent, being reduced in length, according to the number of
births, so much so, that instances are recorded in which the mothers
of nineteen or twenty children, had the portion within the vagina,
completely destroyed ; the orifice is usually deformed, gaping,
larger, and less regular, and sufficiently patulous to admit the intro-
duction of the end of the finger; the lips are thicker and softer
than in the virgin, and are filled with fissures or inequalities, which
are more frequent on the left side of the neck, and are the results
of lacerations of the fibers which occur during the passage of the
child's head through the os uteri, and which have been prevented
from uniting by the lochial discharges. These fissures are of vari-
able depth, and sometimes are so numerous as to divide the lips into
eight or ten small tubercles. These differences are of much import-
ance in legal medicine ; yet they may occasionally be produced by
other causes than parturition, or may even be wanting in the
mother.

The INTERNAL SURFACE of the uterus, presents a narrow,
oblong, irregular cavity, with contiguous walls, which is divided
into two parts, the cavity of the body, and the cavity of the neck.
{Fig. 20.)

The cavity of the body, is triangular in shape, flattened, and when
empty is not very extensive, being hardly large enough to contain
a split almond. At each of its three angles, there is an orifice, the
lower or inferior one leading to, and establishing a communication
with, the cavity of the neck, and the two upper or superior ones
forming the entrance into the Fallopian tubes; the openings in

70

AMERICAN ECLECTIC OBSTETRICS.

these latter are very narrow, and will scarcely admit a hog's bristle.
Occasionally, this opening is divided by a perfect septum, which may
render superfetation possible, and very rarely there exists a congen-
ital deficiency of it. In the absence of the catamenial discharge,
this cavity is constantly moistened by a sero-mucous fluid.

Fig. 20.

Cavity of the Uterus, and the Fallopian Tubes.

A. Fundus of the Womb. F F. The Ovaries.

B. Cavity of the Womb. G G. The round Ligaments.

C. Cavity of the Neck of the Womb. H H. The Ligaments of the Ovaries.
D D. The Canal of the Fallopian Tubes I. The Cavity of the Vagina.

laid open. fc, H. The Uterine Orifices of the Fall-

E E. The fimbriated Extremities. opian Tubes.

The cavity of the neck affords a communication between the cavity
of the body and the vagina ; it is oval and cylindrical, about twelve
or fifteen lines in length, and five or six in its greatest breadth ; it
is fusiform, flattened from before backward, presenting on its
anterior and posterior wall several longitudinal and transverse rugae
or wrinkles, to which the term arbor vitce has been applied ; they are
formed by the lining membrane of the neck, and which are so
arranged as to represent a fern leaf in relief ; they frequently disap-
pear after delivery. On the mucous membrane of the neck are a
number of muciparous follicles, more abundant about the os uteri,
which were mistaken by Naboth for eggs, and' hence have been
called ovula Nabothi, glandula Nabothi, or the glands of Naboth. In
the healthy uterus of the virgin, these follicles can hardly be seen,
but during pregnancy, or when disease attacks the parts, they
enlarge so as to be readily recognized by the eye, and when touched
with the finger they feel like shot. During pregnancy, they secrete
a thick, tough, pellucid, gelatinous mucus, in quantity sufficient to
close up the cavity, and thus prevent any communication between
the cavity of the body and the vagina. The internal surface of the
neck is less vascular than in the body.

INTERNAL ORGANS OF GENERATION.

71

The character of the uterine tissue is very difficult to understand
in its unimpregnated condition, but becomes more manifest during
gestation. Its constituent parts are: an external peritoneal mem-
brane, an internal or mucous membrane, a peculiar tissue, and
numerous bloodvessels and nerves.

The external peritoneal membrane is furnished by the peritoneum,
which, after having covered the posterior surface of the bladder, is
reflected from behind forward, upon the anterior face of the uterus,
covering its superior three-fourths, and extending over the fundus
uteri and posterior surface of the uterus ; it is then prolonged on
the vagina for a short distance, and from thence reflected upon the
rectum. In front of, and behind the uterus, this membrane forms
four small falciform folds; those which are in the space between the
bladder and uterus are named the vesico-uterine, or anterior ligaments ;
and those situated between the rectum and uterus, being termed the
recto-uterine, or posterior ligaments. On the borders of the uterus the
attachments of the peritoneum are quite loose, but become more
intimate toward the median line.

The existence of the internal, or mucous membrane, has been very
much doubted by many anatomists, as may be seen from the follow-
ing observations by Moreau :

" On examination, we find the inner surface of the body of the
uterus to be soft, pulpy, having neither the brilliancy of the peri-
toneum, nor the whiteness of the mucous membrane of the vagina ;
of a reddish or blackish brown color; it generally contains, what-
ever may have been the circumstances preceding the death of the
woman, a brown or dirty gray fluid. When the uterus is macer-
ated, or boiled, or dissected soon after death, it is impossible to
trace the mucous membrane beyond the cavity of the neck. If, on
the other hand, we observe that all the hollow organs provided with
mucous membranes, such as the stomach, intestines, bladder, and
the vagina itself, and which are required, by their functions, to
change in size, present, when empty, a rugose surface and folds
more or less projecting, formed by the lining membrane ; that this
membrane is furnished, moreover, with numerous follicles, which
pour out mucus intended to protect the organ from the irritation of
the substances or bodies they may contain, or which may pass
through them, we will see that no similar arrangement obtains in
the cavity of the body of the uterus ; the follicles are found only in
the cavity of the neck ; they are there disposed symmetrically, on
four opposite lines, two on the anterior and two on the posterior

72

AMERICAN ECLECTIC OBSTETRICS.

paries. If the uterus were provided with a mucous membrane,
could it bear the enormous enlargement resulting from pregnancy,
without lacerations of its internal surface, such as frequently occur
in the vagina at the time of delivery, and of which traces may be
seen almost always in women who have borne children ? Moreover,
in advanced age, we often find obliteration of the cavity of the
body of the uterus, as well as of the tubes. We have long observed
this fact, which is confirmed by the researches of Mayer, reported
by Breschet, and what is very remarkable, this obliteration, the nat-
ural consequence of age, does not extend beyond the internal
orifice, at the point at which we have said the mucous mernbraue
terminates. In organs lined by a true mucous membrane, the
cavity always remains. In old cases of artificial anus, that part of
the intestinal canal below the accidental opening, no longer giving
issue to fecal matter, contracts, but never consolidates.

" "We shall terminate these considerations by a single remark.
The serous and mucous tissues, evidently communicate by means of
the aperture of the Fallopian tubes. Is there a point at which these
tissues change, and are transformed into each other? Undoubtedly
there is; but where is it? Is the serous tissue suddenly arrested at
the digitations of the tubes ? Does it line the cavity of the fimbri -
ated extremity ? Does it extend along the tube as far as the uterus ?
or does the mucous tissue occupy the whole cavity ? Is the latter
prolonged, as it is said, into the cavity of the tube? Does it
terminate at the fimbriated extremity, or extend beyond ? This
can not be demonstrated. If it be impossible to assign the precise
point at which one of these tissues commences, and the other ends,
is it not reasonable to regard the cavity of the body of the uterus,
and of the Fallopian tubes, as respiratory surfaces, intermediate by
their position, organization, and uses, to the serous and mucous
tissues ; upon them the transformation is exerted, but in a gradual,
successive manner, without being able to determiue accurately the
point of mutation.

44 This opinion acquires more value if we observe that the exhala-
tions of the internal surface of the uterus are not identical over its
whole extent. Haller had already found in the cavity of the body, a
serous, whitish, muddy, and thin liquid, which, in the uterus of a
newly born child, resembled milk, while that in the cavity of the neck
was a thick, dense, and reddish mucus. The exhalations of the cavity
of the body of the uterus, present under various circumstances, but
normal for them, the characters of exhalation of the mucous and

INTERNAL ORGANS OF GENERATION.

73

serous tissues, alternately morbid and physiological. Thus, in ordi-
nary health, the matter exhaled by the uterine cavity, has a great
analogy with mucus. When this surface is excited in a special manner
by the act of generation, the fluid produced resembles more the
serous exhalations ; it is a concrescible, plastic lymph, which becomes
condensed, and quickly changed into a species of false membrane,
the caduca. When simply the seat of some fluxive function, as at
the menstrual periods, a phenomenon is manifested which belongs
equally to over-excited or highly inflamed mucous and serous tissues,
a sanguine discharge is established, the afflnxus is dispelled, and
nature resumes her usual course.

" We may hence conclude, that the cavity of the body of the uterus
possesses no mucous membrane ; or if it exists, it has undergone such
modifications as to leave no longer any resemblance to the same
tissue in other parts."

Cazeaux, likewise, observes in relation to this membrane: — " To
the reasons, already offered by Morgagni, Chaussier, etc. , in favor of
its existence, we shall add those presented by Cruveilhier, which ap-
pear to us perfectly conclusive, viz. : 1st. Every organic cavity com-
municating with the exterior is lined by a mucous membrane. 2d.
Anatomy demonstrates that the vaginal mucous membrane is contin-
ued into the cavity of the neck, and tken into that of the uterus, only it
is deprived of its epithelium in penetrating the latter. 3d. When
examined by a lens, the internal surface of the uterus exhibits a papil-
lary disposition, but the papillae are imperfectly developed. 4th*
This internal surface has follicles or crypts spread over it, from which
mucus can be squeezed out, and which, if their orifices be obstructed
or obliterated, become distended by the liquid, and form little vesicles.
5th. It is continually lubricated by mucus. 6th, and lastly ; the inter-
nal surface of the uterus, like all other mucous membranes, is subject
to spontaneous hemorrhages, to catarrhal secretions, and to the
mucous, fibrous, and vesicular vegetations, called polypi; and it is
generally admitted that, wherever there is an identity of action, there
is also an identity of nature."

That the inner membrane of the uterine walls is composed of a
mucous body or tissue, has, according to the recent microscopic
observations of M. Coste, and others, been decided in the affirma-
tive, and which is probably continuous with the lining mucous
membrane of the vagina, and of the Fallopian tubes.

The peculiar tissue of the uterus, which is under the serous
membrane, and is named the middle, fleshy, or .muscular coat of the
6

74

AMERICAN ECLECTIC OBSTETRICS.

uterus; is very dense in structure, resisting, of a dirty grayish color,
being sometimes slightly pearly near the neck, crackles like cartilage
under an incision with the scalpel, and constitutes the greater part,
if not the fundamental structure of the organ. In the unimpreg-
nated state of the uterus, it is very difficult to determine the true char-
acter of the uterine tissue, as it varies in color and density, its fibrous
organizations being concealed by the state of condensation of the
organ. There has been considerable difference of opinion upon this
point, some viewing it as belonging to the fibrous tissue, and others
to the muscular ; the condition of pregnancy, however, removes all
doubt and uncertainty, and presents to us a true muscular tissue.

The arteries of the uterus come from the hypogastrics, or internal
iliacs, under the name of uterine arteries, and from the aorta, or renal
arteries, under the name of ovarian or spermatic arteries. The uter-
ine arteries penetrate the uterus by its lateral borders, and describe a
number of flexuosities in the proper tissue of the organ ; the branches
of the same side frequently anastomose with each other, and unite
on the median line with those of the opposite side. They likewise
communicate above and laterally with the branches of the ovarian
arteries, and terminate in the interior tissue, continuing into the veins ,
and, probably, presenting orifices within the uterine cavity.

The veins follow the course of their respective arteries ; they are
very numerous, have no valves, and empty into the corresponding
trunks: the right spermatic into the inferior cava, the left into the
renal vein, and the uterine veins into the internal iliacs. The
arrangement of the veins, in the uterine tissue, is analogous to that
observed in the corpora cavernosa, and the erectile tissues; and their
orifices on the internal surface of the uterus, are very large during
pregnancy, and become visible just after delivery.

The nerves are derived, one portion, from the sacral plexus of the
cerebro-spinal system, which more especially supplies the cervix
with nervous filaments, and, consequently, renders it more sensi-
tive to the touch than any other part of the organ ; the other por-
tion, being destined to the organic life alone, is from the great
iympathetic nerve, which supplies the body of the organ with fila-
ments, and which will explain to us how most of the vital organs
of the body, especially the brain and stomach, sympathize so
readily with the uterus, both in disease and during pregnancy.
The performance of the several functions of menstruation, con-
ception, and parturition, is, without doubt, chiefly owing to the
influence of the uterine nerves.

THE UTERINE APPENDAGES.

75

The lymphatic vessels are very numerous, and arise from differeut
parts of the organ, forming reticulations, branches and trunks,
which, united in bundles, leave the uterus in three different direc-
tions. The least numerous leave the abdomen by the inguinal
canal, and are distributed to the inguinal ganglia; others, united
to the lymphatics of the vagina, accompany the uterine and
vaginal arteries, and terminate in the hypogastric lymphatic plexus.
But the most numerous arise from the anterior and posterior sur-
faces of the neck and of the body, run toward the lateral borders,
follow their direction, are then united with those of the ovaria,
the tubes, and fundus uteri, ascend with the ovarian arteries and
veins, in front of the psoas muscle, to join the ganglia situated in
front of the aorta, the vena cava, and in the vicinity of the kidneys.

All the above vessels, etc., are very small during the condensed
or unimpregnated condition of the uterus, but increase in size
during pregnancy, and at full term acquire an enormous size, sup-
plying the organ with torrents of blood. The lymphatic vessels,
also, play a very important part in the diseases of the uterus.

Sometimes the uterus is absent entirely, at others but slightly
developed, or it may be malformed, or in an abnormal position. It
is liable to hernia, prolapsus, retroversion, anteversion, inversion,
ulcerations, inflammations, etc., the history and treatment of each
of which conditions are described in my work on "Diseases of
Women."

CHAPTER IX.

OF THE UTERINE APPENDAGES THE LIGAMENTS, THE FALLOPIAN TUBES, AND THE OVARIE8.

The uterus is supported, in the pelvic cavity, by six duplicatures of
peritoneum — two anterior, or vesico-uterine, and two posterior, or recto-
uterine ligaments, to which reference has been heretofore made ; also
two lateral, or broad ligaments, which are much ■ larger and more
important than the others, as within them we find contained the
round ligaments, the Fallopian tubes, and the ovaries. (Fig. 19.)

THE BROAD LIGAMENTS are formed by two duplicatures
of the peritoneum, which, covering the anterior and posterior
faces of the uterus, are prolonged transversely, extending to the
ilia; these two folds rest against each other, and divide the pelvis

76

AMERICAN ECLECTIC OBSTETRICS.

into two cavities, the anterior cavity containing the bladder, and
the posterior the rectum. These ligaments are of a quadrilateral
shape, and from their supposed resemblance to the wings of a bat
extended, have been named the alee vespertilionis. Outwardly, and
below, these ligaments are continuous with the peritoneum that
lines the excavation ; their upper, or superior border is loose, and
extends from the angles of the uterus to the iliac fossae, presenting
three small folds, called alee, or wings. The anterior wing is not
distinctly developed, and is denied by some anatomists ; it is occu-
pied by the round ligament. The middle wing incloses the Fallo-
pian tube, and the posterior contains the ovary and its ligament.

The space between the two serous folds constituting the broad
ligament, is filled by a loose and very extensible lamellated cellular
tissue, continuous with the fascia propria of the pelvis, and which
is traversed by the uterine vessels and nerves. As gestation
advances, and the uterus enlarges, the two laminae of the perito-
neum separate to receive the uterus, assisting to cover its anterior
and posterior surfaces, and in consequence, during the latter month
of pregnanoy, the broad ligaments entirely disappear.

The ROUND LIGAMENTS, or supra-pubic cords, are two in
number, one on each side; they are of cylindrical form, six or
seven inches in length, of a fibrous appearance, and of a grayish
white color. They^arise from the lateral borders of the uterus,
below and a little in advance of the Fallopian tube, and are directed
upward and outward, following the outline of the pelvis ; they are
enveloped in a cellular tissue, and are covered by a prolongation of
the peritoneum, to which the name " Canal of Nuck," has been
given. They enter the inguinal canal on each side, traverse it,
emerge by the corresponding inguinal ring, and divide in front of
and above the pubes into a number of fibrous fasciculi, which are
lost in the cellular tissue of the groins, mons veneris, and labia
pudendi. They contain a great number of veins, which are liable
to become varicose.

There has been considerable controversy as to the structure of
these ligaments, but the investigations of modern anatomists have
ascertained them to be expansions or prolongations of the muscu-
lar fibers of the uterus, containing blood vessels, nerves, lymphat-
ics, and cellular tissue.

The real uses of the round ligaments are not satisfactorily
known ; they are supposed to be, to retain the uterus in its proper

THE UTERINE APPENDAGES.

77

position, and to prevent its displacements. During pregnancy,
chconic affections, or uterine displacements, these ligaments are
subject to inflammation and engorgement, and which conditions
may, probably, be the cause of the pains in the groins, frequently
experienced by women thus circumstanced.

The FALLOPIAN, or UTERINE TUBES, are two cylindrical
canals, from four to five inches in length, of a conical shape, flex-
uous and waving, and extend from the upper or superior angles of
the uterus to the ovaries ; they are placed in the thickness of the
middle wing of the broad ligaments. The internal cavity of these
tubes is very narrow at their uterine extremities, but, as they
extend outwardly, it gradually increases in size, but again con-
tracts just before opening at the fimbriated extremity. The internal
extremities of the tubes are inserted into the superior angles of the
uterus, where they open into the cavity of its body, their orifices
being named the internal or uterine. The external or free extrem-
ities of the tuoes, called the fimbriated extremities or 'pavilion., com-
municate with the peritoneal cavity by an oblong, inverted open-
ing, with digitated or fringed edges, of which one is longer than
the other, curved, and inserted into the external extremity of the
ovary; the other hangs loosely over the ovarium. The openings
at these ends of the tubes are named the free orifices of the tubes.

The tubes are enveloped by the peritoneum, which forms the
outer or external tunic or membrane; the internal membrane is a
prolongation of the uterine mucous membrane (which, however,
is denied by some authors), and is also continuous with the serous
peritoneum ; it is composed of two laminse of fibers, the exterior
of which have a longitudinal direction, while the internal are cir-
cular. Its vessels are derived from the ovarian, and its nerves
from the great sympathetic. The middle la}7er or proper tissue of
the tubes, is a continuation of, and identical in texture with, that
of the uterus.

The Fallopian tubes serve to conduct the fecundating principle
of the male to the ovaries, and to seize the impregnated germ or
ovule of the female and transmit it to the uterus. At the moment
of fecundation, the fimbriated extremity embraces the ovary, and
probably also at each menstrual period.

The OVARIES furnish the ovula which contain the rudiments
of the future animals; they are situated in the thickness of the

78

AMERICAN ECLECTIC OBSTETRICS.

posterior wing of the broad ligaments, behind and below the Fal-
lopian tubes; they are two in number, oblong, oval, whitish, twelve
or fifteen lines long, and flattened from before backward, being
about the size and shape of an almond. Previous to puberty, and
sometimes in virgins and women who have not borne children,
their surface is polished and embossed; but after puberty, owing
to the escape of the ova, they become rough and fissured. Their
superior border is convex and loose; their inferior, straight, and
adhering to the broad ligaments, by which they are maintained in
position, as also by a special one, named the ligament of the ovary,
a dense, imperforate cellulo-fibrous cord which fixes the internal
ovarian extremities to the uterus. The external extremities are
joined to, or approximate the fimbriated Fallopian extremities.
The nerves of the ovaries come from the renal plexus, and the
bloodvessels which are called the ovarian, have a similar origin
with the spermatic vessels in the male. The situation of the ova-
ries varies according to circumstances; in the fetus they are in the
lumbar region ; during gestation they rise into the abdomen along
with the body of the uterus, upon the sides of which they are
attached; and immediately after delivery, they occupy the iliac
fossae, where they sometimes continue through life. It is not
uncommon to find them turned backward, and adhering to the

posterior uterine surface. They like-
wise vary in size, being larger in pro-
portion in the fetus than at maturity,
decreasing after birth, enlarging at pu-
berty and during pregnancy, and
dwindling away as old age approaches ;
they frequently become the seat of or-
ganic alterations. {Fig. 21).
The External Face of the ovary. The external covering of the ovaries
is obtained from the peritoneum, and is named the indusium.
Beneath this covering, the body of each ovary is invested with a
white, dense, fibrous membrane, called the tunica albuginea, which
is the proper tunic of these organs, and which may be considered
as an expansion, or extension of the ovarian ligaments. From the
internal surface of this membrane proceed prolongations which
divide the ovaries into many small cells filled by their proper
tissue. The parenchyma of the ovaries, or tissue proper, is of a
reddish brown color, spongy, dense, and vascular, bearing some
resemblance to the erectile tissue, it is called the stroma; in this

THE UTERINE APPENDAGES.

70

Fig. 22.

tissue are found imbedded a number of small transparent follicles
or vesicles, varying in size from the smallest pin's head to that of
a large shot, the smaller being within — the larger and better devel-
oped more toward the surface. These last sometimes produce
small elevations on the stroma, which give a rough or tuberculous
appearance to the whole ovary ; they are called the ovisacs, or
Graafian vesicles, after De Graaf, who gave a description of them.

The Graafian vesicles number from fifteen to twenty in the adult
female, but with the aid of a microscope many more can be seen
which gradually become developed as the others perfect their func-
tion. They are hardly visible in children and old women, but are
very distinct during the menstrual life. {Fig. 22.)

The vesiculse Graafianaj, con sis
of two separate tunics; 1. The ex-
ternal tunic or tegument, which is firm,
fibrous and vascular in its character,
Hke the stroma or proper ovarian
tissue; 2. The internal tunic, formed
of dense cellular tissue, but thin,
smooth, delicate, diaphanous, and
easily torn; some consider it desti-
tute of vascularity, which is, again?
denied by others. From the close
approximation of these two tunics, it
is sometimes difficult to separate
them.

Ine internal tace or cavity of the M. The mucous surface,
inner tunic contains the nucleus, com- v- The vascular Layer.

. . - m. , , F. The Fibrous Layer.

prising: 1. I he granular membrane, p. The Peritoneal coat,
which is a delicate membrane formed G- Tbe Granular Membrane,
of granules or cellules. This membrane is exceedingly thin and very
easily torn ; its thickest portion corresponds with the free side of the
vesicle, or that portion which is nearest the surface of the albuginea,
and here the granulations are more numerous, constituting the
cumulus proligerus, or discus proligerus. 2. A fluid either limpid,
reddish, or slightly lemon-colored, concrcscible, and composed prin-
cipally of albumen, as it is coagulated by heat, alcohol, and the strong
acids. In this liquid float, vitellary corpuscle , oil globules, and a
great number of small grains, which settle themselves, touching each
other, upon the inner wall of the vesicle, and from the above named

The Ovule in the Graafian Vesicle.

A. The Ovule about 1-10 a line in diameter.
G'. The Granular Cumulus, or Proliferous Disk .
K. The Cavity of the Graafian Vesiclo.

80

AMERICAN ECLECTIC OBSTETRICS.

Fig. 23

granular membrane. 3. The ovule or human egg, which is found in
the center of the proligerous disk, (a, Fig. 22.)

The OVULE, or HUMAN EGG was first discovered as a distinct
organ in the Graafian vesicle by Charles Ernest Baer, though De
Graaf had suggested the idea previously. It is imbedded, as stated
above, in the midst of the proligerous disk, and is perfectly formed
in the ovary during the earlier years of life. It is extremely minute
and hardly to be seen by the naked eye, but when examined with

the microscope, presents an opaque*
rounded appearance. Bischoff says, " The
largest human ovules I have seen and
manipulated, did not exceed the tenth of
a line, being barely perceptible to the
naked eye." As seen by the microscope,
the ovule is possessed of an exterior cov-
ering called the vitelline membrane, trans-
parent zone, cortical membrane or chorion >'
of a substance denominated the yelk or
vitellus, and of a vesicle within the yelk,

termed the germinal vesicle.
A Non-Fecundated Ovule or m, . ,„ , . ,

Human Egg ™ie Vlte"ine membrane is an elastic,

a. The vitelline Membrane, or Transparent thick, hyaline, and transparent mem-
Zone- brane, without a determinate texture,

B. The Vitellus or Yelk. , .. . ,

c. The Germinal Vesicle, or Vesicle of whose external and internal outlines

purkinje,abouti-60ofaiineindiam- aS9urae the appearance of two circular

d. The Germina^spot, from the i-4oo to lines inclosing a transparent ring, (a,

the 1-600 of a line in diameter. Fig 23 )

The yelk or vitellus of the human ovum occupies the cavity of the
vitelline membrane ; it is formed according to Bischoff, of a coherent
indistinctly granular, yellowish, transparent, and viscous mass,
which does not run out when the egg is cut or crushed ; each por-
tion of the zone reserving its particular segment of }relk, or the latter
escaping altogether. It usually fills the interior of the vitelline
sphere completely, though it is sometimes smaller, and its granula-
tions are placed in juxtaposition with its sole envelope, the transpa-
rent zone, (b, Fig. 23.)

Within the yelk, or on one of the points of its circumference, is
discovered a slightly oval, colorless, and perfectly transparent vesicle,
consisting of a very delicate membrane, which incloses a clear and
transparent liquid, but which occasionally contains a few granulations.
This colorless vesicle scarcely measures the sixtieth of a line in

THE UTERINE APTENDAGES.

81

diameter, is surrounded by a mass of deep yellow, and^is identical
in character with that found in the unfecundated eggs of birds.
Fecundation destroys it. This is called the germinal vesicle or the
vesicle of Purkinje (c, Fig. 23) The honor of its discovery is vari-
ously attributed to* Purkinje, Baer and Coste, though the latter is
more justly entitled to it.

If, according to Wagner, the germinal vesicle be attentively exam-
ined with the lens, at four or five hundred diameters, there will be
seen on some part of its periphery, a small, dark, round spot, which
consists of a collection or stratum of fine, small lenticular granules
or globules, and which stratum appears to be the true living animal
germ, existing previously to impregnation. This is called the germ-
inal spot, and was cotemporaneously discovered and described by
Professor Rudolph Wagner, of Germany, and T. Wharton Jones
of England. Two, or more germinal spots have been met with in
the mammiferse. (d, Fig. 23.)

The ovule, therefore, previous to impregnation, is composed : 1. of
an exterior tunic, the vitelline membrane, within which is contained,
2, a yelk, which again incloses, 3, a vesicle, the germinal vesicle, within
which we find, 4, a dark spot, the germinal spot or germ from which
it is presumed the future man originates, after it has been fertilized
by the male semen.

The Graafian or ovarian vesicles experience considerable changes
during menstruation, conception, and after impregnation. The inves-
tigations of Gendrin, Negrier, Pouchet, Raciborski, Jones, Lee,'Pat-
terson, Bischoff, and several others, have led to the belief, which is
becoming general among medical men, that the phenomena of
menstruation is owing to the development or maturity of these vesi-
cles. Until the period of puberty these ovisacs are hardly discerni-
ble, but on the completion of this period, they develop themselves?
maturing periodically, in women once in every twenty-eight days.
At each period of ovulation or menstruation, a vesicle becomes much
enlarged, its upper segment rapidly rises above the surface of the
ovary, forming a prominence there about the size of a small nut (a,
Fig. 24) and the walls of the vesicle become less transparent in con-
sequence of the thickness of the internal membrane, and the hemor-
rhage that finally takes place in the interior of the vesicle. The
quantity of blood effused within the vesicle adding to the amount of
fluid it naturally holds, distends it so much as eventually to lacerate
or rupture its walls, at a point about a line in extent, the situation of

82

AMERICAN ECLECTIC OBSTETRICS.

Fig. 24.

which can be distinguished by its
reddish appearance and its more
elevated projection. The ovum
and contents of the vesicle es-
cape into the peritoneal cavity,
or are carried down to the womb
by the Fallopian tube ; the ves-
icular walls shrink up, their
cavity holding a clot of blood
about as large as a cherry, which
Diagram showing the Ovary, and a Graafian ^as OOZed from the torn mar-
Vesicle at its highest degree of develop- gins, and which, as the vesicular
ment, and just before its rupture. cavity diminishes, is gradually

A. The hypertrophies Vesicle. -i it rrn • i? j.1

bcc. Radiated cicatrices left by pre- absorbed. The margin s of the

viousiy ruptured Vesicles. fissure approximate, giving rise

to more or less cicatricula of various forms, being sometimes linear,
again radiated, and at others triangular; when recent, they are red,
but gradually become brown, forming deep furrows by their
retraction.

This rupture of the vesicles not only takes place at the period of
impregnation, but also at each period of ovulation ; and the scars
which are left, instead of being an evidence of so many previous
conceptions, as was formerly supposed, are merely the remains of
ruptured ovisacs.

CHAPTER X.

OF THE CORPUS LUTEUM.

The termt CORPUS LUTEUM, or yellow body{ is applied to the
remains of the Graafian vesicle, after the ovum has been expelled from
H, whether from copulation or from menstruation. And as there has
been considerable discussion upon this body, regarding its presence
as a sign of conception, it becomes a matter of some moment, in a
medico-legal point of view, to determine its true character.

The corpus luteum is a peculiar glandular mass, varying in size
from that of a pea to half an inch in length ; it is of a dull yellow
color, friable in consistence, having a lobulated appearance, with
slight convolutions, somewhat resembling a section of the human
kidney, and very vascular ; according to Montgomery, an injection

THE CORPUS LUTEUM.

83

through the spermatic artery will easily pass into its substance. The
true corpus luteum is found in the ovary of a recently pregnant woman,
and varies in size and appearance according to the period of gesta-
tion, gradually diminishing in size, and losing its deep yellow color,
until about the fifth month after full term, when it disappears, leaving
a small pit over the place it had previously occupied. So that the
idea that it is a permanent formation is erroneous. Dr. Montgomery,
who has bestowed considerable attention to this subject, thus speaks
of its appearance:

"Its center exhibits either a cavity, or a radiated or branching
white line, according to the period at which the examination is
made; if within the first three or four months after conception, we
shall, I believe, alwaj's find the cavity still existing, and of such a
size as to be capable of containing a grain of wheat at least, and
very often of a greater dimension ; this cavity is surrounded by a
strong white cyst; and, as gestation proceeds, the opposite parts of
this cyst approximate, and at length close together, by which the
cavity is completely obliterated, and in its place there remains an
irregular white line, whose form is best expressed by calling it radi-
ated or stelliform. This is visible as long as any distinct trace of
the corpus luteum remains. I am unable to state exactly at what
period the central cavity disappears or closes up, to form the stel-
lated line. I think I have invariably found it existing up to the
end of the fourth month. I have one specimen, in which it was
closed in the fifth month, and another in which it was open in the
sixth — later than this I have never found it.

" After the period of gestation has been completed, or the con-
tents of the uterus prematurely expelled, so that gestation ceases,
the corpus luteum soon begins to exhibit a very decided alteration
in all its characters, until, at length, it is no longer to be found in
the ovary. The exact period of its total disappearance I am unable
to state ; but I have found it distinctly visible, so late as at the end
of five months after delivery at the full time; but not beyond this
period ; and the eorpus luteum of a preceding conception is never to
be found along with that of a more recent, when gestation has
arrived at its full term ; but in cases of miscarriage, repeated at
short intervals, it may.

"At the time of delivery the corpus luteum is neither so large
nor so vascular as at the earlier periods of pregnancy, except the
woman should happen, at the time of her death, to be laboring
under inflammation of the uterine system : in which case the corpus

84

AMERICAN ECLECTIC OBSTETRICS.

luteum partakes of the turgescence of the other parts, and, very
remarkably, of their increased vascularity , a striking instance of
which is represented in a preparation in the writer's museum, taken
from the body of a woman who died of inflammation of the womb,
two days after delivery ; the central radiated white line is very dis-
tinct, and the vessels having been injected, the substance of the
corpus luteum is quite crimsoned, and, externally, the ovary con-
tinues to exhibit the superficial cicatrix, and the alteration of form
produced by the projection of the part containing the corpus
luteum."

With reference to the corpus luteum, as a test of conception,
there is some diversity of opinion ; some viewing the existence of
a true corpus luteum, so called, as an infallible test ; while others
maintain that no real distinction can be made between the true and
false corpus luteum, or that which forms independent of impregna-
tion. This question still remains unsettled, though the observa-
tions of Dr. Montgomery, which are corroborated by other investi-
gators, as Haller, Pouchet, Haighton, Jones, Lee, Raciborski, etc.,
seem to confirm the former view; he remarks: "I have seen many
of these virgin corpora lutea, as they are unhappily called, and have
preserved several specimens of them ; but not in any one instance did
they present what I should regard as even an approach to the
assemblage of characters belonging to the true corpus luteum, the
result of impregnation, from which they differ in all the following
particulars :

" 1. There is no prominence or enlargement of the ovary over them,

" 2. The external cicatrix is almost always wanting.

" 3. There are often several of them found in both ovaries, espe-
cially in subjects who have died of tubercular disease, such as
phthisis, in which case they appear to be merely depositions of tuber-
cle, and are frequently without any discoverable connection with
the Graafian vesicles.

" 4. They present no trace whatever of vessels in their substance,
of which they are in fact entirely destitute, and of course can not
be injected.

" 5. Their texture is sometimes so infirm that it seems to be
merely the remains of a coagulum, and at others appears fibro-cel-
lular, like that of the internal structure of the ovary; but never
presents the soft, rich, lobulated, and regularly glandular appear-
ance which Hunter meant to express, when he described them as
'tender and friable, like glandular flesh.'

THE CORPUS LUTEUM.

85

" 6. In form they are often triangular or square, or of some figure
bounded by straight lines.

" 7. They never present either the central cavity or the radiated or
stelliform white line which results from its closure.

" This latter peculiarity, in common with several others observable
in these spurious productions (whether occurring in virgins or in
other women, but not the result of conception), even when they are
connected with a Graafian vesicle, depends on their different mode
of formation ; a circumstance which deserves especial attention, as
pointing out the essential difference between a very large class of
these pseudo-structures and the true ones.

"The history of their formation appears to me to be this: acci-
dental or morbid determination takes place toward a vesicle, in con,
sequence of which it is distended with fluid, and either bursts and
discharges its contents (in which case there may be found an external
cicatrix), or the fluid is again absorbed; but, in either case, there is
often deposited on the internal surface of the vesicle, a substance
somewhat resembling the corpus luteum in color, but in general not
more than about one-sixteenth of an inch in thickness, and entirely
destitute of bloodvessels : sometimes it is very much thinner even
than this, amounting to little more than a mere layer of coloring
matter lining the vesicle. In this condition I have often found them,
the vesicle being enlarged to three or four times its natural size, full
of fluid, and its internal surface of a bright yellow color ; but when
the vesicle collapses, either in consequence of rupture of its coats,
or the absorption of the contained fluid, the inner surface of this new
deposit closes upon itself, and forms an irregular line of junction,
which is generally darker than the rest of the structure, and not
unfrequently they present the yellow color only on the circumference,
while their center is so dark as to be almost black ; but, from their
situation, they are entirely without lining membrane, to form either
a central cavity or white stellated line, which, in the true corpus
luteum, is formed by the closure of the inner coat of the vesicle; for
the same reason also, these accidental formations are in general
much smaller than the others ; and they are moreover totally with-
out vessels in'their structure, so, that, however minutely the rest of
the ovary may be pervaded by fine injection, not a particle of it will
pass into the bodies thus formed."

Among those who do not consider it as a test of conception, but
only as an evidence of perfect ovulation, may be named Hume,
Blumenbach, Bischoff, Cuvier, Cazeaux, Prof. Meigs, of Philadelphia,

86 AMERICAN ECLECTIC OBSTETRICS.

etc. This latter gentleman, in his recent "Treatise on Obstetrics."
maintains that the yellow matter found in a corpus luteum, "is of
the same apparent structure, form, color, odor, coagulability and
refractive power," as the yelk of eggs. His views are based upon
the following observations :

" 1. Equal masses of yelk and corpus luteum are equally yellow.

" 2. They alike fill the tube, before the focus is got, with a bril-
liant yellow light.

" 3. They alike consist of a pellucid fluid, in which float granules,
corpuscles containing yellow fluid, oil-globules, and punctiform
bodies.

" 4. These bodies, placed on the same platine, and diligently com-
pared together, ^exhibit the [same forms, size, tint, and refractive
power.

" 5. Yelk, boiled hard, is granular and friable; it is coagulated by
heat.

" 6. Corpus luteum, boiled, becomes hard, granular, and friable —
it is coagulated by heat.

"7. Both substances, raw or boiled, stain paper alike of a yellow
color.

" 8. There is this difference : the crushed mass of corpus luteum
contains patches of laminar cellular tela, detritus, and blood-disks
forced out by the compressorium ; which can not occur in the yelk,
as that is contained within a vitellary membrane, in which its corpus-
cles are free ; whereas, in the corpus luteum, they are confined by
the delicate cellular substance lying betwixt the concentric laminae of
the Graafian follicle.

" 9. They refract alike.

" 10. Projected on a live coal, they alike give out the odor of roasted
eggs."

These opinions require further investigation, in order to establish
their correctness.

The formation of the true corpus luteum, is thus explained by
Ramsbotham : " It has been demonstrated that the Graafian vesicle
possesses two membranes : one adhering to the substance of the
ovary, the other inclosing the fluid in which the ovule of Baer
floats. "When a fruitful connection takes place, a great determina-
tion of blood is made to that ovary which supplies the germ. The
gland becomes larger, rounder, and more vascular than the other ;
to the touch it feels fuller and softer. But the vascularity is con-

■

THE CORPUS LUTEUM.

87

fined to one spot — the neighborhood of the corpus luteum ; and the
increased size and softness result, not so much from an alteration in
the structure of the whole organ, as from the quantity of lymph and
fluid blood deposited between the membranes of the vesicle, which
is converted into the characteristic yellow gland-like mass. This
effusion causes the vessel to be thrown prominently out toward the
peritoneal surface ; the attenuated coats burst, or rather an opening
is formed by absorption, and the fluid, with the ovule previously
contained within them, passes into the tube."

\

P AET II.

OF GENERATION.

CHAPTER XI.

THEORIES OF IMPREGNATION.

Generation comprises those several phenomena which are neces-
sary to the development or reproduction of organized bodies, and
which include, in the human family, the various functions of men-
struation, copulation, conception, gestation, and labor or parturition.
The particular method by which generation is effected in the organic
world, varies according to the character of the organization, being
more simple as this approaches elementarity. Moreau has described
the several modes somewhat as follows :

1. Generation may be spontaneous, doubtful or unknown, as in
case of intestinal worms.

2. It may result from an individual, by division or separation of
its parts ; a, by simple division of the individual, each fragment
producing a new individual, as in the instances of fissiparce. or vege-
tables, cuttings of trees, and animal infusoria ; b, by separation of a
vegetable product, either on the exterior or interior of the indi-
vidual, as with the gemmiparoe, or vegetables, buds of trees, and some
polypi.

3. It may be effected by impregnation, requiring the connection
of the sexes, and varies according to the character of the sexes. 1st.
As in hermaphrodism, or where the sexes are united in the same
individual, and which may be divided into, a, where the sexes are
united in a common envelope, in which instance one individual is
sufficient, as with many vegetables and some mollusca; bf where the

THEORIES OF IMPREGNATION.

89

sexes are separated on the same individual, as in monoecious plants ;
c, with the sexes separated in the same individual, but requiring the
connection of two similar individuals, and even reciprocal impreg-
nation, as with gasteropodous mollusca, and worms. 2d. When
the sexes are separated on different individuals, and which may he
divided into, a, without approximation, the parents and offspring
remaining unknown to each other, as with dioecious plants, and
fishes; 6, with approximation, but without copulation, the parents
knowing each other, but the offspring being ignorant of them, as
with the batrachia, or reptiles, frogs, toads, etc.; c, with approxima- *
tion and copulation, as with the majority of insects; the reptilia.
chelonia, sauria, ophidia, birds and mammalia.

4. This last method of generation by copulation and approxima-
tion, offers great varieties, differing according to the mode of devel-
opment of the fecundated product, thus ; a, by incubation, as with
insects, and the greater part of reptiles and fishes ; b, by external
incubation, as with birds ; c, by internal incubation in the parts of
the mother, without adhering to them, as with some of the ophidian,
and ovo-viviparous animals; d, by an organ of gestation, to which
the impregnated product adheres, from which it derives the greater
part of its nourishment, and from which it separates after a certain
time, as with all the mammiferous animals. To this last and most
complicated process belongs the generation of man.

The mode in which fecundation is accomplished in the human
being belongs more especially to the physiologist's department to
determine; but as the matter has long been a subject of inquiry,
and presents a field of interest to many, I will briefly refer to the
various opinions that have from time to time been advanced and
maintained in the medical world.

In the male, the semen, or spermatic fluid secreted by the testi-
cles, is undoubtedly the agent especially called into action in the
function of reproduction ;. this is manifest from the fact that,
removal of the testes not only destroys all sexual propensity, but
likewise renders the individual forever after incapable of begetting
offspring. The same may be said in relation to the removal of the
ovaries of the female; she loses all sexual inclination, the procrea-
tive functions are annihilated, and all those graces, emotions, and
feelings which distinguish the sex, gradually disappear. Observa-
tions have likewise been made in relation to this matter, of a highly
7

90

AMERICAN ECLECTIC OBSTETRICS.

interesting character, to some of which a very concise reference will
here be made.

Spallanzani, during his investigations, noticed, that as soon as the
temale frog laid an egg, the male immediately cast a fluid upon it,
which soon impregnated it. He then confined the genitals of the
male frog in a silk bag, and ascertained that in this condition
impregnation could not occur. He, likewise, applied to some of the
freshly laid ova, a small quantity of the male semen or fluid which
he had previously collected, and impregnation was the result. He
also instituted similar experiments on a bitch in heat, and which
had been kept confined for twenty-three days before heat commenced,
in order to prevent the approach of any dog; the result was, that by
injecting nineteen grains of semen into the vagina, at 100° Fah.,
fecundation followed, and, at the proper period, the animal gave
birth to three pups which bore a strong resemblance to herself and
the dog from which the semen was gathered. Prevost and Dumas
arrived at similar results ; they expressed the semen from the testi-
cle of a frog, and after diluting it with water, they placed some ova
upon it, wrhich became prolific. According to these gentlemen, it
is important to dilute the male fluid in order to have the experiment
prove successful.

Sir Everard Home, in his "Lectures on Comparative Anatomy,"
vol. iii, p. 315, records a similar experiment on man, performed by
Hunter ; the husband was affected with hypospadias, which pre-
vented him from impregnating his wife ; Hunter advised him to
inject his semen into his wife's vagina through a warm syringe ; the
result was, she became pregnant.

These experiments, with others of similar character, prove con-
clusively, that the agents engaged in the generating process, are the
semen furnished by the male testes, and the ova of the female.
Spallanzani, as well as Prevost and Dumas, determined from further
and satisfactory trial, that the fructification of4 the ova only took
place when brought into actual contact with the male semen ; thus
refuting the doctrine held by some physiologists, that impregnation
did not require this mutual junction, but was effected merely by the
presence or influence of a seminal halitus or vapor.

Another point of inquiry among physiologists, was, the method
by which the spermatic fluid is carried to the ovaries ; some con-
tending that impregnation was effected in the uterus, while others
maintained that the semen was conducted to the ovaries, and that
fecundation was possible even beyond the angles of the uterus;

THEORIES OF IMPREGNATION.

01

indeed this fluid has been found on the surface ot the ovaries, by
Adelon, Bischoff, and other investigators. But by what means it
reaches the ovaries, has never yet been satisfactorily explained ; for
the male penis, certainly bas not sufficient power to throw it beyond
the uterus.

Various views have likewise been supported at different periods,
relative to the manner in which the union of the male and female
principles necessary to the formation of a new being, is effected,
and how this new being, of whatever species, comes to bear the
impress of the mental and physical features of one or both parents.
But the solution of these particulars is still involved in mystery.
The oldest theory on this subject, is that of epigenesis, which holds
that the new being is created entirely anew, and at the moment of
conception, receives at once the materials necessary for its forma-
tion, one portion being derived from the testes of the male parent,
the other from the uterus or ovaries of the female. Aristotle,
Galen, and others, supposed that the material furnished by the
female was the menstrual fluid ; and Hippocrates considered that
the female supplied all the substance required for the development
of the future being, while the male fluid merely contained that
vivifying principle necessary to impart vitality to the female mate-
rials. This theory of epigenesis, with various modifications, was
the prevailing one for many years, and was for a time renewed by
Buffon in the beginning of the seventeenth century, whose views
were entirely speculative and untenable. His notion was, that the
growth and nourishment of individuals during youth, was effected
by certain organic molecules common to both sexes; but which
being required in less quantities for these purposes at maturity,
the predominance was emitted by the male testes with the sper-
matic fluid, and also by the ovaries, or female testes, as he termed
them, for the purposes of reproduction of the species. He imagined
that the body of each parent supplied each of these molecules with
atoms derived from its various parts, and that whichever parent,
afforded to the newly organized being the major portion of these
molecules, thetresemblance to that parent would be the most marked.

During the sixteenth century another theory was originated,
being based upon investigations and discoveries of the physiologists
of that period, among whom may be named, Leuwenhoeck, Har-
vey, De Graaf, and others. It is termed the theory of evolution, and
was strenuously supported under some form or other, during the
whole of this century. The adherents of this theory maintained

02

AMERICAN ECLECTIC OBSTETRICS.

that the germ of the new being existed in only one of the parents,
while the other furnished the principle which communicated life
to it. They were divided into ovarists, and animalculists or sper-
matists. The ovarists, among whom I may mention Harvey as
the principal, having discovered numerous small vesicles in the
ovaries, which apparently decrease according to the number of
conceptions, held that these vesicles were the fetal germ, which
only needed the animating power of the male semen to usher the
new being into existence. But this view was objected to by many,
on account of its exclusiveness, whereby the male fluid had but a
minor part to perform; beside which, if the semen merely exerted
a vivifying influence upon these vesicles, it did not explain why
the offspring so often resembled its male parent.

In consequence of these objections, a different opinion was sup-
ported by those who were called animalculists, and which originated
principally from the microscopic discoveries of Leuwenhoeck
and other investigators, who found myriads of animalcules in the
male semen. These held, that after having been thrown into the
uterus during copulation, the animalcules perished, with the excep-
tion of one or two, which entering the Fallopian tubes, were con-
veyed through to the ovaries, and there deposited and nourished in
a nidus formed by the ovum. As this spermatozoid progressed
in growth, it ruptured the nidus which inclosed it, and was again
conveyed to the uterus to be nourished and preserved until the period
of parturition. To this view, wherein the female merely supplies the
nourishment for the embryo furnished by the male, an objection
similar to the one above is suggested, as to the cause of resemblance,
in many instances, to the female parent.

Those who desire to have these several views more in detail, are
referred to the several physiological treatises in which they are fully
related and discussed ; and as they have become at the present day
obsolete, a mere glance at them was deemed all-sufficient in the
present work. But, before terminating this subject, a reference to
the views of physiologists of the present day must be made, without
which, this portion of our work would be imperfect.

In Part I, will be found a description of the ovaries, Graafian
vesicle, ovule, germinal spot, etc.; these are the discoveries of recent
physiological investigators, and have been the means of effecting a
revolution in relation to the views of impregnation, giving
rise to a theory, the ovular theory, which is, undoubtedly, more in
proximity to the truth, than any of the previous doctrines which have

MENSTRUATION — CONCEPTION.

03

been held on this subject, The theory is, that the egg, ovum or
germ is supplied by the female, in whom it exists in indeterminate
quantities; that at the age of puberty, these germs commence matur-
ing; at their period of ripening, they rupture the vesicular tissue in
which they are contained, and pass from it, being accompanied by a
sanguineous discharge called menstruation or ovulation, the appear-
ance of which is significant of the fact that the female has reached
the age at which she is capable of giving birth to children : these
ovules escape either into the peritoneal cavity, or into the womb
through the Fallopian tubes, and pass off with the menstrual flow,
or are retained in consequence of fecundation.

On the other hand the male supplies a fluid in which is contained
minute, round and granulated bodies, the spermatic granules, as well
as bodies possessed of motion, like the epithelial cells, which are not,
however animalcules, but more properly spermzoons or spermato-
zoids; these bodies, by some unknown power of force, attraction or
velocity, are conveyed to the uterus tubes or ovaries, when coming
into contact with the nude, uncovered ovum, through some inscruta-
ble agency, probably an intermingling or mutual permeation of the
male semen and female germ, animalization takes place, and a creature
is brought into existence, which, possessing certain elements derived
from each parent, will necessarily present mental and physical
resemblances to either or both of them.

Repeated experiments on animals have proved, that any obstacle
to this contact of the germ and semen, will prevent conception.

CHAPTER XII.

MENSTRUATION CONCEPTION.

At a certain age the female reaches the period of puberty, which
is made manifest by a sanguineous discharge from the uterus,
occurring periodically once a month, and which is called menstrua-
tion or ovulation. It has likewise many other names applied to it,
as menses, catamenia, courses, terms, periods, monthly sic/mess, menstrua,
flowers, monthlies, times, etc. It is not a secretion, but an effusion or
hemorrhage, very much resembling venous blood, and is undoubtedly
blood rendered impure by the addition of mucus and epithelial scales
with which it meets during its flow.

94

AMERICAN ECLECTIC OBSTETRICS.

As a general rule, the discharge, in females of this climate, is
established at the fourteenth or fifteenth year, though it varies with
some, oftentimes appearing as early as the twelfth or thirteenth year,
and again not until the seventeenth or eighteenth. In the former
instance, it is termed precocious menstruation, and is significant of
an unnatural increase or development of certain organs, at the expense
of others ; it is commonly followed by premature death, especially if
an early marriage resulting in pregnancy, should take place, in
consequence of these unseasonable and abnormal indications of
puberty. In the latter instance, the term, tardy menstruation, is
applied, and which is usually the result of some debility or disease,
that may eventually destroy the female.

Climate, constitution, education, modes of life, etc., atFect the
appearance of this discharge ; it being earlier in warm climates
than in cold, and in city females than in those of the country. It
likewise appears earlier and more abundantly in females of a ner-
vous temperament, than in those who are phlegmatic.

The period of ovulation is one of the most interesting in the life
of a female, and is ushered in by many symptoms and changes in
her mental and physical developments, that manifest themselves
gradually. A remarkable advancement toward the perfection of
the reproductive organs is presented ; the ovaries rapidly enlarge,
and change from their previous long, flat and smooth condition, to
one in which they are large, oval, rounded and embossed; the Fal-
lopian tubes become elongated, their fimbriated extremities widened,
and the fimbriae enlarged; the uterus becomes more fully supplied
with blood, and its tissue more florid ; the body and fundus likewise
obtain more rotundity and development than the cervix, which
appears proportionally shorter and narrower ; the vagina is widened
and dilated, and its vascular structure is supplied with increased
quantities of blood, and its mucous folds augment in number. The
pelvis becomes larger and wider, with a diminution of its inclina-
tion forward ; the pubic region more prominent, round, and covered
with hair; the labia pudendi more amplified, red, and sensitive;
the hips more projecting, and inclined outwardly; the pelvic cavity
enlarged ; and the breasts rounder, full, and prominent, with the
nipples projecting, more sensitive, and the areola of a darker hue.
The whole person improves in grace and elegance, and the voice
becomes more sonorous and melodious. ■

Corresponding with these modifications of the physical system,
are, changes in the mental character; the gay, light-hearted girl,

MENSTRUATION — CONCEPTION.

95

loses her playfulness, and assumes the dignity of womanhood ; she
becomes more reserved, more sensitive, aud full of sympathy ; she
manifests strong attractive feelings toward the opposite sex, and
seeks to love as well as to be loved ; the social aud moral sentiments
become of a purer and more exalted character ; a great fondness for
children is displayed; and in her we find the most perfect combina-
tion of modesty, devotion, patience, affection, gratitude, loveliness,
and Christian virtue.

The menstrual discharge being a sign of maturity and fertility of
the reproductive organs, it does not appear during childhood, nor
in old age, usually ceasing at the ages of from forty to fifty, though
occasionally it extends to a very advanced age. The period of its
cessation is termed the " turn of life," or " the critical time of life,"
from which time women cease to bear children, aud on account of
the various unpleasant, and often serious symptoms presenting at
this period, its approach is much dreaded by nearly all of them.

The amount of fluid expelled, varies in females, averaging from
six to eight ounces; some will lose only four ounces at each ovula-
tion, and others twelve, and yet each will remain in health, because
the system of each is controlled and affected according to its indi-
vidual wants, habits, strength, and activity. The discharge usually
continues from three to six days, occasionally from eight to ten, and
must, as a general rule, have revealed itself before impregnation can
take place. Yet I have known several females who became mothers
without ever having had any previous menstrual flow ; these, how-
ever, are the exceptions, and depend upon causes of which I confess
myself ignorant. In the above cases, however, menstruation occurred
at the proper period after parturition, showing that the previous
non-ovulation, depended upon neither malformation nor malorgan-
ization. In no one of them was the female less than sixteen years
old, and accouchment occurred within twelve months from the
nuptial rites. All cleanly women wear a napkin during ovulation,
which is retained in its place in a manner similar to a T bandage,
for the purpose of concealing their situation, which it does by
absorbing the fluid discharged; from four to twenty of these, nap-
kins will be worn during one menstrual term.

As has been observed in another place, the menstrual hemorrhage
is merely the periodical phenomenon of that function which matures
and discharges an ovule from the ovary, and fecundation, as a gen-
eral rule, can not take place without the healthy and perfect per-
formance of this function. At this period there is a plethoric,

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hyperbaric or excited condition of the uterus and other reproductive
organs, accompanied with an exhalation of blood from the uterine
vessels, all of which symptoms are relieved by the escape of the
ovulnm, and the sanguineous flow. This discharge is liable to
several derangements, as amenorrhea, dysmenorrhea, monorrhagia,
etc., which do not properly come within the limits of this work,
but which will be fully treated of in my work on "Diseases of
Women."

An ovum may become impregnated, and yet conception not
ensue, because it may pass into the uterus, and fall from thence into
the vagina, and thus be lost; or it may be removed by hemorrhage,
or mucous discharges. Conception takes place, only when the
fecundated ovulum becomes attached or adherent to the uterus,
Fallopian tubes, etc. Hence women may be often impregnated,
and seldom conceive.

The period during which conception takes place most readily is
immediately after ovulation, yet, physiologists have not agreed on
this point. Ritchie supposes that the escape of ova is not limited
to the menstrual period, but is taking place constantly, and conse-
quently that fecundation is possible even during the intervals
between menstruation. Raeiborski and Pouchet, are of opinion,
that, the act of copulation may accelerate the ripening of the ova,
by exciting the ovaries to a more vigorous play of their functions.
To this view Prof. Meigs objects, as I believe, with good reason ;
he says, " As to the impression still entertained by some reputable
authors, that the discharge of the ovule depends upon the aphro-
disiac orgasm, it is too unreasonable an hypothesis ; too unreasona-
ble, I say, because, the dehiscence being the effect of absorptive
power, and not of a lacerative or vulnerative force, it is idle to
attribute to a momentary orgasm, which perhaps has no direct influ-
ence on the circulation within the ovaries, a result that recpires for
its effectuation many days of the slow operation of the absorbents
of the ovarium."

Bischoff remarks, " During the years in which a woman is sus-
ceptible of impregnation, an ovum ripens, and is separated from
the ovary every four weeks, this phenomenon being accompanied
by simultaneous hemorrhage from the uterus. This periodical
maturation of an ovum, is the first and most essential condition of
conception and pregnancy. At this time alone will coitus be followed
by conception; at all others this last will be impossible." Raeiborski
believes that continence for three days previous to ovulation, and

MENSTRUATION — CONCEPTION.

07

nine days subsequently, will very much lessen the chances of
fecundation; he observes that few women conceive at a distant
period from the catamenial flow, and states, that " of fifteen women
who specified accurately the period of their latest menstruation, as
well as the dates of the connubial act, five evidently conceived from
coitus taking place from two to four days previous to the period at
which the catamenia was due. In seven, conception dated from
coitus occurring two or three days after menstruation ; in two, it
took place at the actual period of the catamenia; and in one,
so long as ten days after the latter had disappeared." Nnegele
observes, that the calculation of nine months and eight days from
the last appearance of the menses, has never, in his investigations,
failed to fix the term of gestation.

Pouchet asserts that only within the first twelve days after men-
struation, is impregnation possible, and Prof. Meigs supports him
in this view. Yet there are recorded instances which prove the
reverse of this, as, the case reported by Montgomery, in which
fecundation was effected three days previous to the catamenial dis-
charge ; the reported case of Dewees, in which it was accomplished
within a week of the menstrual period, etc.

Notwithstanding all this diversity of opinion relative to the sub-
ject, the investigations of physiologists undoubtedly prove that the
chances of impregnation increase the sooner coitus ensues after
menstruation, and that after the eighteenth or nineteenth day from
this function, they become very much diminished. As to the con-
ception following an embrace, which happened several days previous
to the menstrua, I would suggest, that it is possible the vitality of
the male semen or spermzoons may be preserved within the female
organs for some time, and consequently, if they thus exist until the
period at which the discharge of the matured ovum occurs, contact
between the two, would effect its necessary result. That this is a
reasonable view of the matter, can not be doubted, especially when
we remember that Bischoff, Wagner, and others, have found living
spermzoons in the vagina, uterus, tubes a#d ovaries of animals,
upon which they experimented, for some hours after copulation.

But, however interesting these discussions and investigations may
be to the physiologist at the present day, they are of no importance
to the accoucheur in a practical view, and as a labored exposition
of the facts and opinions recorded concerning them is not actually
necessary in a work like the present, I have, therefore, endeavored to
be as brief and limited as a mere'glance at the subject would admit.

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CHAPTER XIII.

OF PREGNANCY.

When the fecundated ovum becomes attached to some portion of
the uterus, conception is said to have taken place, and the peculiar
condition of the woman, from the moment of conception to the
period of parturition, is called pregnancy or utero- gestation ; this
usually comprises nine calendar months, or two hundred and eighty
days from the last menstrual show, or one hundred and forty days
after quickening — the time at which most females perceive the first
motions of the fetus, and which generally occurs about the twentieth
week after conception. Although this is the period which seems to
have been generally recognized from the earliest ages, yet it is not
invariable, as it occasionally terminates sooner, and again, may
extend to even ten months, of which there are well attested cases
on record. The determination of this subject is one of great diffi-
culty, as we can seldom ascertain the precise moment of fecunda-
tion, and yet it is one of immense importance, from the fact that
the legitimacy of the offspring may depend upon a correct decision.

The only method by which we can ascertain the commencement
of utero-gestation, is by reference to the period of the last men-
strual flow, as well as to the time of quickening; but even these
means are very uncertain, as conception may occur sometime during
the intermenstrual period; beside which, the period of quickening
varies in different women. On account of these difficulties, laws
have been established in several nations, fixing the term within
which legitimacy is acknowledged by them; thus, in France, the
"Code Napoleon," admits the legitimacy of child born within
three hundred days after wedlock, divorce, or death of the husband;
and if born after that time, its legitimacy may be contested, though
it is not to be viewed as a bastard. In Prussia, three weeks beyond
the usual time are allowed, or three hundred and one days. In Scot-
land, ten calendar months are considered the extent of legitimacy.
In England and in this country, the limit of gestation is not deter-
mined by law.

That the term of utero-gestation varies in many females is, I
believe, generally admitted by observing accoucheurs of the present
day, and the existence of the laws on this subject, in the countries
above referred to, are strong confirmations of the possibility of pro-
tracted gestation. Indeed, I have met with several instances in

OF PREGNANCY.

99

which I had every reason for believing that the pregnancy had been
prolonged to two and three weeks beyond the usual period ; and
two, in particular, in which I positively know that gestation was
continued for ten months. Drs. Blundell, Desormeaux, Hunter,
Montgomery, Rigby, Hamilton, Burns, Dewees, Atlee, Velpeau,
Merriman, Moreau, and many others, have met with similar
instances, in which the term of gestation had extended from one to
four weeks beyond nine calendar months. Their reported cases, in
connection with investigations made on animals, as rabbits, sheep,
cows, mares, etc., that likewise are found to vary considerably in
their periods of gestation, certainly afford the strongest evidence in
favor of prolonged pregnancy. Relative to this subject, Dr. Mont-
gomery justly observes: "We can not imagine why gestation
should be the only process connected with reproduction, for which
a total exemption from any variation in its period should be claimed.
The periods of menstruation are, in general, very regular; but who
is there who does not know, that as there are, on the one hand,
women in whom the return of that discharge is anticipated by sev-
eral days, so there are also many in whom the return is postponed
an equal length of time, without the slightest appreciable derange-
ment of the health. Again, menstruation and the power of repro-
duction in the female, very generally, indeed almost universally,
ceases about the forty -fifth year, in these countries ; yet occasionally
instances are met with, in which both are prolonged ten or fifteen
years beyond that time of life ; and a similar variety is observable,
in the period of the first establishment of that function in the sys-
tem. If we turn our attention to brutes, the conditions of whose
gestation so closely coincide with those of the human female, and
are less disposed to have it disturbed, we can not for a moment
doubt the fact, that there is a great irregularity in the term of gesta-
tion in different individuals of the same species."

Another point to determine, is the earliest period at which a child
may be born, consistent with its existence subsequently. This is
likewise a subject of much moment, involving the reputation of a
mother, the legitimacy of offspring, and the peace and happiness of
families, especially in those instances where the fetal developments
exceed those which are generally found at the various periods of preg-
nancy. I remember an incident which occurred some years since, and
which I will relate here, to show the importance of prudence. I was
called to attend a lady who had aborted three months after her marri-
age : the fetus presented all the appearances of one between the fourth

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and fifth months, and on seeing it, I innocently remarked, " it is a
good-sized one." This imprudent remark occasioned much unhap-
piness in the minds of the husband, the mother of the lady, and
herself; and they each inquired of me, in private, if I supposed
there "was anything wrong ?" — having -reference to the wife's chas-
tity. I had long known each of the parties, before their marriage,
and had no reasons whatever for the most distant idea of want of
purity and virtue, and it was from this consciousness of undoubted
integrity of character, that the observation was inadvertently made —
and I so replied to their inquiries. About eighteen or nineteen
months afterward, I delivered this lady of a male child, at full term,
which having been weighed on the day of its birth, was found to
exceed twelve pounds. Here was an extraordinary development of
size at full term, and a similar excess of growth was undoubtedly
the case with the previously aborted fetus.

The seventh month is generally viewed as the shortest period in
which a viable child may be born, yet there are many instances in
which it has occurred still earlier. Dr. Dewees states, that he has
known instances of this kind: one "in which labor habitually
occurred at the seventh month, and two, in which it regularly took
place at the eighth month of pregnancy." In Scotland, a child born
six months after marriage, or after the death of the father, is con-
sidered legitimate. Carpenter, in his Physiology, mentions an
instance in which a child, born twenty-five weeks after wedlock,
lived between six and seven months, and was declared to be legiti-
mate by the Presbytery of Scotland. Dr. Dodd and Dr. Christian
relate similar cases, as well as many other plr^sicians. Dr. W.
Hunter observes, that " a child may be born alive, at any time after
three months ; but we see none with powers of living to manhood,
or of being reared, before seven calender months, or near that time.
At six months it can not be." The fact that a child, born at the
seventh month of gestation, may subsequently continue to live, is of
importance in another point, viz.: the induction of premature labor.

Upon these various deviations from the most common course of
pregnancy, it is not my intention to offer any speculative views, as the
present work is intended to be, not one of theorizing, but of utility,
in a practical point, to those who consult its pages; I will, therefore,
leave this subject, by observing, that an opinion in these cases
should always be given very guardedly and reservedly, lest by a hasty
and improper decision we tarnish the reputation, and consequent
happiness of the innocent.

SIGNS OF PREGNANCY.

101

It sometimes happens that the ovum, after impregnation, does not
reach the cavity of the uterus, hut becomes attached to the interior
walls of the Fallopian tubes, abdomen, etc., in consequence of which,
from want of a proper and natural connection with the mother, the
development of the ovum is much retarded, is seldom perfected and
disease often attacks it; under these circumstances, a well-formed,
living fetus could not be produced. I am aware, that some writers
object to these facts as being without foundation ; but the objections
are commonly presented by those who support the theory that the
male semen never extends beyoud the uterine cavity, within which,
alone, fecundation occurs. As before stated, the spermatic fluid has
been found in the tubes, and on the ovaries of various animals by
rigid investigators; beside, the fact that fetal formations, without
the uterus, do occasionally exist, is, in connection with the above, an
evidence tending, to say the least of it, to support a belief of the
possibility, as well as the probability, of fecundation occurring
beyond the uteriue cavity.

When the impregnated ovum reaches the uterus, and is developed
within its cavity, it is termed a normal or uterine pregnancy, which
is divided into simple uterine pregnancy, when there is but on e fetus ;
compound or multiple pregnancy, when there are more than one ;
and mixed, complex, or complicated pregnancy, when, with the existence
of the fetus, there is also, a mole, hydatids, or some morbid condi-
tion of the uterus, or its appendages. When, instead of passing
into the uterus, the vivified ovulum becomes fixed upon the tubes,
abdomen, etc., it is called extra-uterine pregnancy, of which there are
several varieties, according to the place of adhesion of the ovum,
and which I will refer to hereafter. To those pathological condi-
tions which simulate pregnancy, often misleading both the patient
and her physicians, and which occur independently of true concep-
tion, the term.fal.se pregnancy has been improperly applied.

CHAPTER XIV.

SIGNS OF PREGNANCY.

Physicians are frequently consulted to decide the existence or
non-existence of pregnancy, in cases where it may be of immense

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importance in determining the reputation of a female, the legit-
macy of a child, or even the life of a new being, and in instances
when a pregnant woman is condemned to capital punishment.
Hence, a knowledge of the signs common to pregnancy, can not
be too thoroughly understood by the accoucheur. Women with
illicit offspring, when suspected and interrogated, will almost always
endeavor to mislead us by an obstinate denial, and even by an
appearance of much indignation ; and this will usually apply to all
females, whether married or not, who desire to abort, or destroy
their conception. We can not therefore be too cautious iu giving
full credence to the statements of any female upon this subject,
unless we have a sufficient acquaintance with her to justify implicit
confidence in her assertions; and we should always depend upon
our own knowledge of the symptoms, rather than upon any light we
may elicit from the female.

Again, in cases where there is no desire or interest to deceive, as
when pregnancy is suspected from the presence of abdominal
enlargement, suppressed menstruation, morning sickness, etc., it will
often require all the skill of the physician to diagnosticate correctly,
and, if an incorrect opinion is pronounced, it will frequently place
him in an extremely mortifying situation. It is not many years
since, that a celebrated Professor plunged the trocar into the gravid
uterus and shoulder of the fetus of a lady, whose condition he mistook
for dropsy; I knew an instance where a female, supposed to have
erred, was examined by two or three physicians, who decided that
she was some three or four months advanced in pregnancy ; she
denied the charge, but it was of no avail, her friends forsook her,
and even her parents became harsh, severe, and cold toward her ;
she pined away in secret, hiding her grief from the world, and in a
, few months died. Au investigation being held, a morbid growth
within the uterus disclosed the true cause of her symptoms. Many
instances of similar character might here be related, showing the
value and importance of a full acquaintance with all the signs
which are to guide us in our investigation and decision. We
should exercise great discretion, and rely entirely on the indisputa-
ble evidence of our senses ; not forming our opinion on one'symp-
tom, but on a combination of unquestionable symptoms, and if the
least doubt be entertained, we should unhesitatingly express it ;
for it is much safer to remain in uncertainty, than to pronounce
an incorrect diagnosis. Females usually suppose themselves preg-
nant, when after intercourse, they find a cessation of menstruation,

SIGNS OF PREGNANCY.

103

followed by an enlargement of the abdomen at a proper time and
fetal movements, and generally they are correct, yet all these signs
may be apparently present without conception.

To determine a recent conception is not only difficult, but as far
as the physician is concerned, absolutely impossible ; yet many
females resolve this point very correctly, from certain voluptuous
sensations, peculiar to each, individually, experienced during a
fruitful copulation; and where they have previously given birth to
children, having felt similar sensations at the period of fecunda-
tion, we have on subsequent occasions, when these occur, some
grounds for believing them to be again pregnant. Yet it is com-
monly the case that " cold women," as they are called, are more
easily impregnated, than those warm, ardent, amorous beings, who
during copulation, enjoy exquisite voluptous sensations, with
spasms, and nervous agitation.

The dryness of the penis when withdrawn after an embrace, and
the retention of semen by the female, are looked upon in some
sections as undoubted ( evidence of fecundation. An anxiety or
depressed condition of the woman a few days afterward, paleness
of countenance, a dull, sunken, languishing appearance of the
eyes, with a bluish circle surrounding them, spots on the face of
various sizes, and swelling of the neck, have all been enumerated
as signs of earty conception, but they are extremely uncertain and
doubtful.

It is only when pregnaucy has somewhat progressed that we are
enabled to diagnosticate with any degree of confidence, aud the
more advauced this is, the more correctly can we decide. The
signs of pregnancy are divided into the RATIONAL and the
SENSIBLE; the rational are again subdivided into general, local
and sympathetic.

The general signs, are those which result from increased activity
of the nutritive functions, and from the modifications which take
place in the nervous system. The pulse is more frequent and
strong, full and hard ; occasionally, in the latter months, inter-
mittent and contracted ; the blood is said to be buffy and more
plastic; respiration is more active with an augmentation of the
heat of the body; and all the secretions are more abundant, with
increased odor. The changes in the nervous system are usually
the greatest and most remarkable. The sensibilities become more
refined, the female becomes more susceptible as well as more liable
to moral and physical influences; sometimes her nature appears

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completely changed, so that those who were kind, loving and
amiable, become peevish, irritable, jealous and malicious, and vice
versa; the silent become loquacious, and the talkative become
taciturn : in some, the intellect becomes more active, and they are
rendered more subject to nervous derangements. If diseases are
already existing in the female their further progress is either
retarded, or more rapidly hastened toward a serious termination.
Pregnancy renders the female system more liable to disease, con-
stituting a condition called puerperal, which is induced by concep-
tion— is more fully developed as pregnancy advances — and reaches
its maximum point at childbirth; it then gradually diminishes
until after lactation, when it ceases; manifesting itself again, in a
greater or less degree, during every subsequent pregnancy. It is
owing to this puerperal condition that pregnant and lying-in
women are more liable to epidemic and other diseases, and which
are usually more rapid and severe at this time than during the
ordinar}r state and habits of the animal economy. Although
these signs are indicative of pregnancy, yet in the early months
they are very obscure, and when taken by themselves at any
period, very uncertain, affording very little aid in diagnosis unless
associated with the others hereafter mentioned.

Among the local signs, that upon which females place the greatest
reliance, is the suppression of menstruation; this is, to be sure, a
valuable and most important indication, and one that is very com-
mon with pregnant females, yet too much confidence must not be
placed in it as an unerring sign. It often happens that women
fail to menstruate for one, or several periods in succession without
conception being present, and this may or may not be accompanied
with an augmented protuberance of the hypogastric region. This
suppression may be owing to cold, functional or organic disease of
the reproductive system, or other cause, which should always be
carefully investigated with a view to a correct solution. Again,
there are many instances where menstruation is present during
pregnancy — others, where females have conceived without any
previous monthly flow, and, occasionally, some ovulate regularly
only when pregnant. Usually, when the catamenia have failed in
non-pregnant females, there is a greater or less derangement in the
general health, but when the health continues in its ordinary
condition, with a gradual enlargement of the abdomen, morning
sickness, and the darkened areola, we have strong reasons for
suspecting pregnancy, especially in the married woman. In the

SIGNS OF PREGNANCY.

105

unmarried, where illicit commerce is strenuously denied, the
diagnosis will be involved in much uncertainty and difficulty ; yet
the physician should not bestow a too ready credence on the state-
ments of his patient, but rather postpone a positive declaration,
until the other signs have advanced so far as to give an undoubted
indication of the true state of the case. When the least doubt
exists in the mind of the practitioner, he should be very particular
not to prescribe or administer any remedies tending to the restora-
tion of the monthly evacuation.

A change in the color of the vulva, from its natural pinkish hue, to
a bluish tint, has been named as a sign of pregnancy ; but as this
is probably owing to an obstructed circulation, pelvic tumors or
other abnormal conditions may produce it. It is usually more
marked when the female is in the erect or sitting posture, and dis-
appears more or less in the recumbent.

A change in the color of the skin, called ephelis, and sometimes
morph, or mask, accompanies many women during every pregnancy.
' It is a brownish, yellowish, or earthy colored stain or freckle, of
greater or less extent, usually occupying the forehead, cheeks, and
even the neck and breast, but is not a constant sign of pregnancy.
It is a minor sign, and one, probably, more important among those
females who have been disfigured by it in previous conceptions.
It often becomes permanent, remaining after parturition, and
occasioning considerable uneasiness to the female ; at this time
efforts may be made to remove it. I have succeeded in several
instances, by employing as a lotion, the saturated aqueous solution
of Sulphuret of Potassa, to be applied on the stain three or four
times a day, in connection with small doses of a mixture of Rhei,
2 ; Leptandrin, J ; and Bicarbonate of Potassa, 1 ; to regulate the
bowels and restore the cutaneo-hepatic sympathetic relations; but
a subsequent conception has always brought with it a return of the
dark spot. /

The sympathetic signs are usually confined to the digestive sys-
tem, and are only useful as means of diagnosis when taken in
connection with the more positive sensible signs ; they sometimes
become so severe and troublesome as to require treatment, for
which the reader is referred to the chapter on " Disorders of
Pregnancy, and Treatment." Among the sympathetic signs are
nausea, or morning sickness, vomiting, anorexia, pica, malacia, acidity
of stomach, heartburn, and toothache, which are more common in the
earlier months of pregnancy, gradually disappearing in the latter
8

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AMERICAN ECLECTIC OBSTETRICS.

mouths, being followed by constipation, hemorrhoids, and more or
less headache.

All the rational signs, of whatever subdivision, are only import-
ant when accompanied with the sensible signs, and when they
occur together, the diagnosis is rendered more easy and certain.

The SENSIBLE SIGNS are subdivided into the visible, the
audible, and the tangible.

The visible signs are those which may be recognized by the eye,
as enlargement of the mammaz. The breasts, during the earlier
stages of pregnancy, acquire new life from sympathy with the
uterus; the lactiferous glands are aroused into action, the breasts
increase in magnitude, becoming round, tense, hard and tender,
with frequently a pricking sensation in them, which sometimes
continues during gestation, and at other times the enlargement
diminishes about the fourth or fifth month, and may not appear
again until near the period of parturition, or even subsequently.
Occasionally the axillary glands enlarge.

Simultaneously with the augmentation of the breast, or about
the commencement of the third month, the nipples increase in
size, and sensitiveness, and are sometimes quite painful, they
become of a deeper red, and it is often the case that a yellowish or
milky fluid can be obtained from them. The surrounding skin
likewise becomes tense, thin and more transparent, and the veins
more conspicuous. The enlargement of the breasts, and increased
size of the nipples are most commonly present during pregnancy,
yet taken alone, they can not be depended on as signs, for preg-
nancy often exists without them, and again, they may originate
from other causes, as ovarian or uterine tumors, amenorrhea, etc.

The areola, shortly after conception, becomes changed from its
natural pink color to a deep brown, and which is a more valuable
sign in first pregnancies than succeeding ones, as in the latter it
would be difficult to decide whether the change was owing to the
former pregnancy, or the one under examination, especially, ii
only a short time has elapsed between them. By some medical
men, especially Smellie, and Hunter, it was viewed as a positive
Bign of pregnancy. Cazeaux says, "and I should diagnosticate the
existence of pregnancy, with a degree of confidence, in a young
woman who had never borne children, and whose breasts presented
both a brownish-colored areola, the tubercles (sebaceous glands),
and the freckled characters before described." But, notwithstand-

SIGNS OF PREGNANCY.

107

ing, this sign has its objections; it is sometimes absent during
pregnancy — it may be modified by the color of the skin, being
more distinct in women with dark hair and eyes, and less so in
blondes and brunettes; and it has been present when conception
did not exist, being induced by disease, as amenorrhea, or organic
disease of the ovaries, or uterus ; all of which should be consid-
ered during the investigation.

With this alteration of color, the papillae, or sebaceous glands
which are seated under the skin of the areola, and especially near
its margin, become enlarged, appearing like small tubercles, and
which is considered a more positive sign of pregnancy than the
areolar discoloration.

The secretion of milk, is a sign of some value; yet the accoucheur
must remember, that it has occcrred in females who were not preg-
nant, likewise in children; and that cases are on record, where
milk has been obtained from the breast of the male. In females,
this secretion may be present in consequence of the sympathy
existing between the breasts and the reproductive organs in a state
of disease; instances of which are frequently met with; conse-
quently, this sign is only of importance when attended with others
of a positive character.

Enlargement of the abdomen, affords to the public a strong pre-
sumption of pregnancy, because it is an invariable concomitant of
this condition. Yet a mere dependence on this sign will often
deceive us, as it may be present from many other causes than
pregnancy. Thus, the accumulation of adipose matter in the
omentum, and walls of the abdomen, ascites, uterine and ovarian
tumors, amenorrhea, tympanitis, etc., will cause its enlargement.
An appreciable increase of size, in the abdomen, is commonly
observed about the third month, and if with it we have enlarge-
ment of the breasts, discolored areola, cessation of menstruation,
with usual health, and previous morning sickness, the inference is
strong that conception exists; yet even these may mislead us;
hence, the necessity for great caution in forming a diagnosis on
this subject, can not be too strongly enforced.

Previous to the third month, or soon after conception, the
abdomen generally becomes flat, its anterior wall retracts, and
approaches toward the vertebral column; but about the third
month, it commences to project, first on the median line, gradually
increasing and extending from the pelvic to the umbilical and epi-
gastric regions, reaching this last at full term, and leaving a

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sunken, or depressed appearance over the iliac fossae. In women
who have had several children, the abdomen inclines more forward
and downward, from laxity of the parietes, while with those in
their first pregnancies it is usually less projecting, but larger and
more uniform. The volume of the abdomen, at different stages of
gestation, likewise varies from several circumstances, as twins,
amniotic dropsy, etc. If, with the above appearances, we ascertain
that the umbilicus is sunken at first, and then becomes gradually
more prominent as the projection of the abdomen proceeds, our
suspicions of pregnancy are still further corroborated. During
the latter months of pregnancy the umbilicus may be thrust for-
■ ward from one-fourth of an inch to even an inch beyond the ante-
rior surface of the abdomen; and this projection may also origi-
nate from the presence of pathological tumors within its cavity.

Quickening, a term applied to a fluctuation, or fluttering sensa-
tion, experienced about the end of the fourth month, may be men-
tioned in connection with the augmentation of the abdomen. By
some authors this is considered as the result of life being imparted
to the fetus at the time it is felt ; by others, it is viewed as being
caused by the impregnated uterus when rising from the pelvic
excavation, etc. It is undoubtedly owing solely to the fetal move-
ments, which take place as soon as the embryo attains size and
strength sufficient to make its motions felt by the mother, and
which generally commences about the eighteenth or twentieth
week of utero-gestation. However, pregnancy may exist, and no
quickening have been experienced by the mother; again, females
often mistake other sensations for this symptom, as a flatulent
motion, etc.; yet, if the sensation continues to increase in strength,
until the fetal movements can be distinctly felt, all doubts will of
course be removed. If, during the latter months of gestation,
firm and continued pressure be made by the fingers against oppo-
site sides of the uterus, it will produce such disturbance to the
fetus, as to make it move vigorously ; or, if one hand be placed on
one side of the abdomen, and the same point on the opposite side
be struck with the other hand, the fetus is very apt to move
actively. The motions of the child, if it be alive, may likewise
be determined, by dipping the hand in a bowl of cold water, and
applying it suddenly over the abdomen. It must be borne in
* mind, that although the motions of the fetus are a strong evidence
of pregnancy, yet its absence does not prove the reverse condition,

SIGNS OF PREGNANCY.

109

as the child may be dead, or very feeble. In the strict sense of
the word, quickening really occurs at the period of conception.

Among the visible signs, may be named a peculiarity observed in
the urine of some pregnant women, first described by M. Nauche,
in 1831, and after him by several other gentlemen. The urine on
being allowed to stand in a glass, for some twenty or twenty-four
hours, presents on its surface a number of brilliant, crystalline
granules, resembling small specks, or oblong filaments, irregularly
isolated, which often unite, forming a transparent layer or pellicle
about a line in thickness, which can only be seen in certain posi-
tions. After a few days a portion of this pellicle gradually falls to
the bottom of the glass, forming a white, milky crust there. At
one time this pellicle was considered a positive proof of preg-
nancy, but recent investigations by Dr. E. K. Kane, of Philadel-
phia, have determined, that kiesteine, the name given to this mate-
rial, is not peculiar to pregnancy, but may occur during the
presence of milk in the breasts, especially if it be not freely dis-
charged from the mammae, and that its presence is rather an indi-
cation of the existence of this mammary secretion, than of
pregnancy.

The audible signs, are those detected by the ear, with or without
the aid of the stethoscope, among which is, the placental sound, or
bruit de souffle, which is variously represented as resembling the
blowing of air, the cooing of a dove, the drone of a bagpipe,
having a peculiar rasping sound, similar to that which is heard in
the carotid arteries of chlorotic females, in varicose aneurisms, and
in some cardiac affections ; this sound is owing to the arterial and
venous circulation of the walls of the impregnated uterus, as well
as to pressure upon the arteries, and not to the utero-placental cir-
culation; it is always synchronous with the mother's pulse, and is
occasionally heard in the course of the linea alba, but more fre-
quently on the sides of the abdomen, over the course of the iliac
arteries; sometimes it can be heard over a large extent of surface
When the female is placed ip such a manner as to remove the
pressure of the gravid uterus upon the arteries, as upon her knees
and elbows, this sound can not be heard; and there are cases in
which it can not be detected, although the motions of the fetus
may be distinctly felt. It is first heard about the fourth or fifth
month of pregnancy, though some writers profess to have observed
it even before the end of the third month, and becomes more audi-

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ble as gestation advances. This is neither a constant, nor a posi-
tive sign of pregnancy, for it may be owing to various other
causes, as aneurism, abdominal tumors, or whatever may compress
the arteries, and has been heard even after delivery ; hence, but
little confidence is bestowed upon it at the present day.

The sound of the fetal heart, differs entirely from the placental
souffle; it closely resembles the ticking of a watch, and differs
materially from the mother's pulse in frequency and rapidity,
beating from one hundred and twenty to one hundred and forty in
a minute, the pulsations being sometimes so rapid as to render it
impossible to count them, but returning to their natural character,
without any cognizable cause.

The pulsations of the fetal heart are first perceptible between
the fourth and fifth months, and are more commonly heard on the
anterior inferior portion of the abdominal wall, just above the
iliac fossa, occasionally on the median line, and over an extent of
two or three inches ; as the fetus advances in growth the pulsa-
tions become more marked.

These pulsations, whenever they can be heard, afford positive
evidence of pregnancy, yet their absence is no indication of non-
pregnancy, as the fetus may be dead, very feeble, or it may be in
a position unfavorable to the transmission of sound to the ear; or
an excessive quantity of the liquor amnii may destroy the sound.
The presence of twins, and even the position of the child in the
uterus has been attempted to be determined by the presence of
these pulsations, but from the discordant and contradictory state-
ments made by authors in relation to these points, no confidence
can be placed in them; though if the sound of the fetal heart
should be heird emanating from two points, it would be of some
value in the diagnosis of twins. In auscultating a female suspected
of pregnancy, especially during the fourth, fifth or sixth months,
it is advisable to have her lie upon her back, with the thighs flexed
upon the abdomen ; the bed should be of a hight sufficient to
allow the practitioner to auscultate without stooping too much,
which would render it impossible for him to hear any internal
sound. The stethoscope, and not the ear, should be applied to the
abdomen, which is less disagreeable to females, and it should be
placed, first, over the part where the pulsations are most commonly
heard, and then changed as may be required.

The tangible signs, or those which are ascertained by the touch,

SIGNS OF PREGNANCY.

Ill

are exceedingly important in assisting us in our diagnosis of preg-
nancy, for by them we are not only enabled to determine this con-
dition, but also its degree of advancement; hence, every prac-
titioner should fully qualify himself to perform this operation of
touching or mauual examination.

The examination per vaginam or vaginal touch, is usually made
by means of the index finger, which is always preferable to the
middle finger, as recommended by some writers; occasionally,
however, it may become necessary to introduce both the index and
middle fingers at the same time; this, however, is usually done for
the purpose of reaching more deeply into the vagina, and the
touching should be accomplished with the index finger alone, for
if both are employed, there may be a double perception, and an
uncertain, confused idea of the condition of the parts under exam-
ination. The practitioner should be able to manipulate with
either hand, as occasion should require, and should be very care-
ful that his finger nails are not too long or pointed, in order to
avoid giving pain or injury, as well as to render the touch more
easy, delicate, and certain; long finger nails, in an accoucheur,
manifest negligence and carelessness, and are always inexcusable.
The finger, in order to admit of its easy introduction, should be
anointed with oil, lard, pomatum, butter, etc., and not with
mucilaginous liquids, as advised by many, because these last do
not adhere so firmly to the skin, and are less apt to protect the
finger, especially if there be excoriation of it, from the absorption
of any infectious virus which may be present. As to the length
of the finger necessary to become an expert accoucheur, that is of
little consequence, as the shortest fingers and smallest hands
become as perfect in this art, as the longer and larger.

The female may be placed in the erect, recumbent, or sitting
posture, according to circumstances; thus, for ballottement, or for
the detection of uterine displacements, the erect position should
be assumed; to ascertain the advance of pregnancy, the size of the
uterus, tumors, etc., the recumbent position is the best, with the
female lying upon her back or side; the latter is preferable in
these cases, with the head and chest elevated and inclined forward
and the inferior extremities separated and flexed as much as pos-
sible on the abdomen, so as to relax the abdominal muscles, and
consequently render the examination more easy. In some instances
where the erect position can not be maintained, or where the
recumbent would give rise to suffocation, as in debility, dropsy,

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dyspnoea, etc., the sitting posture will be found the best, in which
the patient is so placed upon a chair that the weight of the body
rests upon the sacrum, the body being inclined backward and the
vulva being beyond the edge of the chair, so as to allow the opera-
tion to be performed. If the patient be standing, the physician
should place himself in front, resting on that knee opposite to the
operating hand, with the other knee, demiflexed, and placed
between the limbs of the female, to act as a support for the elbow
to lean upon, thus preventing the hand from trembling, and allow-
ing the examination to be made more easily. If she is in the
recumbent position, he will place himself on that side of his patient
corresponding with the hand he intends to employ, and should bo
seated on a chair of a suitable bight. The woman, in whatever
position she may be placed, must not be exposed, but have a proper
covering over her.

The extended hand of the operator is now to be passed lightly
and quickly along the internal surface of the thigh nearest to him
if she lies on her back, or of the lower one if she lies on her side,
toward the nates, and as soon as it is arrested by the soft parts, and
the fissure between the nates recognized by the index finger, this
must then be carried forward toward the vulva. Some writers
advise the finger to be carried to the symphysis pubis and then
moved downward and backward; but in doing this, friction against
the clitoris and meatus urinarius must necessarily ensue, but which
should always be carefully avoided. The practitioner must be
careful not to commit an error by introducing the finger within the
rectum, instead of within the vagina, indeed, this could only happen
from inattention, or an inexcusable carelessness. On finding the
vaginal opening, the condition of the external labia, its size and
firmness must be ascertained by passing them between the thumb
and index finger, and the fourchette may also be detected if there
has been no previous labor, but if there has been, it will be absent,
and its place supplied with inequalities. The finger is then to be
pressed nearly backward with its palmer surface directed toward
the symphysis pubis, examining, as it passes along the urethral
canal, which is generally more swollen in pregnant women than
others, the condition of the mucous membrane of the vagina,
whether smooth or wrinkled, whether any abnormal conditions of
its walls are present, and the width and length of the vaginal canal.

When about one-third of the finger has passed into the vagina,
the wrist is to be strongly depressed, and the finger directed nearly

SIGNS OF PREGNANCY.

113

vertical, when the bas fond of the bladder, the vaginal cul-de-sac,
and cervix uteri may be examined. At this time of the operation
the thumb is to be extended and applied against the anterior face
of the symphysis pubis; the other three fingers will vary in posi-
tion according to circumstances, being generally extended on the
perineum, pressing it upward, and sometimes flexed with the
thumb, into the palm of the hand, for the purpose of ballottemeut,
or examining the parts on the anterior plane.

However, if the female lies upon her side, with her back toward
the practitioner, the positions of the fingers will be nearly reversed,
the palmer surface of the index will be looking toward the sacrum,
and the other fingers and thumb more or less flexed in the palm.

The same method of introducing the finger may be pursued for
the detection of malformations of the pelvis, the dilatation of the
os uteri, the presentation of the fetus, etc. The various changes
which the neck of the uterus undergoes during pregnancy, will be
described in the following chapter, to which the reader is referred.

Abdominal palpation or exploration, may assist us in forming a
correct diagnosis of pregnancy, and can be practiced in all cases,
with a few rare exceptions, which may be owing to an excessive
thickness of the abdominal walls. In making this examination
the female must be placed in a recumbent position, on her back,
with the hips elevated, the head flexed on the chest, and the thighs
on the abdomen, which position completely relaxes the muscles of
the abdomen. At first, both hands are to be applied over the
abdomen, to determine its size, form and hardness, more especially
in the hypogastric region.

To ascertain the growth of the uterus, the practitioner will place
the ends of the eight fingers immediately above the symphysis
pubis, and make pressure until they feel the resistance of the
uterine globe, and in this manner he will continue to ascend grad-
ually until the fundus is gained, which may be known by the
absence of any further resistance, and by the fingers sinking deeper
and gliding over the convexity of the fundus. If pain should
accompany the examination, or the abdominal muscles be in a state
of great tension, further procedure must be postponed until a
more favorable occasion. The uterine globe invariably retains its
oval form, is circumscribed, presenting a resistance somewhat of
an elastic character, and which is firmer in the early months of
gestation than during the latter; and the practitioner will often be

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enabled to recognize movable, irregular masses, and even the vari-
ous parts of the fetus. The elastic character of the uterine parietes
is not so appreciable when the enlargement of the organ is depend-
ent upon chronic disease, and should it be owing to the presence of
a mole within its cavity, it will be impossible to decide, unless at
an advanced period, when the absence of the fetal movemeuts,
pulsations of the heart, and the fetal inequalities, may furnish
grounds for such a supposition.

The vaginal touch is usually practiced at the same time with
the abdominal exploration, especially in the earlier months of
pregnancy. The finger introduced within the vagina, is applied
on the neck, or against that portion of the uterus between the neck
and the symphysis, or between the neck and the sacrum, while the
other hand is placed above the pubis, pressing firmly to recognize
the uterine tumor. The womb being thus located between the
finger within and the hand without, the degree of its enlargement
may be ascertained, by instituting a comparison between it and
the non-gravid organ. Again, the finger may elevate the uterus,
which will be recognized by the hand, or the hand may depress
the organ, which will be felt by the finger, and thus its condition
and situation be determined. However, during the first three or
four months there are no unequivocal signs of pregnancy, and the
practitioner will often be mistaken should he depend on any of
them at this time, yet he may, in nearly all instances, satisfy him-
self of the unimpregnated condition of the uterus.

Another mode of determining the presence of pregnancy, is from
the passive movements of the fetus in utero, and which is called
ballottement; these motions depend upon physical laws, and are
entirely independent of the vitality and muscular strength of the
fetus, as they are present whether it be dead or alive. As a cer-
tain size and weight of the fetus is required for ballottement, it
can not be produced in the early months of gestation, or if it can,
it is imperceptible. The sensation of ballottement is, according to
most writers, analogous to that produced by striking a marble ball,
which has been placed in a bladder full of water, or in a glass tube
likewise filled with water suspended in a vertical position, with
the lower end closed by a diaphragm of bladder or parchment.
The blow is to be given with the palmar face of the finger applied
just under the spot where the ball rests, striking from below
upward, when the ball ascends in proportion to the force of the

SIGNS OF PREGNANCY.

115

blow, and when this force is exhausted, it descends and falls back
upon the finger which displaced it, communicating a shock to it,
and which motion and sensation constitute ballottement.

To perform the ballottement, the female should be standing, with
her shoulders placed against some solid body, as a wall, to cause a
projection of the abdomen. The finger, properly oiled, is then to
be introduced into the vagina as far as the neck, and should be
applied anteriorly, on that portion of the uterus between the sym-
physis pubis and the projecting portion of the neck, at which point
a smart blow is to be given, sufficiently strong to cause the fetus to
ascend ; the blow should be made from below upward, and from
behind forward, which last may be effected by suddenly flexing the
first phalanx as the shock is imparted. As the uterus is generally
inclined forward with its long diameter corresponding somewhat
with the axis of the superior strait, this last direction of the blow
will be required to cause the fetus to ascend in the direction of the
uterine long diameter, otherwise, it will merely be pushed against
the posterior wall of the uterus, being displaced without ascension.
At the time the blow is imparted, the operator should place his
other hand upon the abdomen, over the fundus, to firmly fix the
uterus in its position, and a short time after the shock has been
communicated to the fetus, he will press upon the fundus from
above downward, to hasten the descent, and thus increase the inten-
sity of the sensation to be experienced by the finger within the
vagina, which finger is to be held firmly and steadily against that
portion of the uterus which has been struck, until it has received
the shock of the descending fetus, or until a sufficient length of
time has passed for that result. Ballottement is best obtained when
the woman is in the erect position; yet, there may be cases in
which, from inability to stand, the recumbent posture may be
employed, when the operator will have to place the finger at various
i points both auterior and posterior to the vaginal projection of the
cervix.

Ballottement may be effected at the fourth month of utero-ges-
tation, though it is frequently absent during this as well as the
fifth month ; at the sixth or seventh month it is very distinct, and
conveys a sensation similar to that of a solid ball inclosed in a fluid
and falling upon the finger, as above described. As the fetus con-
tinues to grow, ballottement becomes less distinct, is hardly percepti-
ble at the end of the eighth month, and is impossible in the latter
weeks of pregnancy. During the early period of ballottement it

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may be advisable, in cases where accuracy is absolutely required,
and in which it can not be recognized, to make several trials; as
from the fact that the small size of the child allows it to easily
change its position, this sign may be present one day, and be quite
impossible to detect at another.

By many authors ballottement is considered as a pathogno-
monic symptom of pregnancy, being equally applicable to the dead
or living fetus, and, indeed, we know of no other cause to produce
it, than the actual presence of a child within the uterus. How-
ever, the practitioner should always ascertain that there is no dis-
placement of the uterus which might create a mistake, as in ante-
version, and also that the shock communicated to his finger is not
from stone in the bladder; each of these conditions, has, heretofore,
occasioned some difficulty in determining true ballottment.

From what has been stated, it will be observed, that in order to
determine the condition of pregnancy with certainty, the prac-
titioner will be obliged to procure a delay until the motions of the
fetus and other signs are manifested with force and distinctness, and
which usually will be at the fourth or fifth month ; though, from
feebleness of the fetus he may have to wait for a still longer period.
In all difficult cases, the physician, when called upon, should never
positively affirm the existence of pregnancy, until he has distinctly
perceived the pulsations of the fetal heart, ballottement, and the
changes in the condition of the uterus; inordinary cases, an experi-
enced practitioner can form a correct diagnosis from these last
uterine changes, as described in Chapter XV; the rational signs
afford but little evidence of any value or certainty.

Occasionally, the physician is called upon to determine the stage
of pregnancy; this is often very difficult. However, reference
should be had to the length of time which has elapsed since the
last ovulation, the position of the fundus uteri, the condition of
the cervix, ballottement, auscultation, and the time of quickening,
if it have taken place, and from all which, an approximation to
the period of gestation may be obtained. As to the sex of the
fetus in utero, I know of no method of determining it. Neither
is there any reliable mode of ascertaining the presence of twins.

CHANGES IN THE UTERUS DURING PREGNANCY.

117

CHAPTER XV.

CHANGES IN THE CONDITION OF THE UTERUS DURING PREGNANCY.

From the moment of conception the uterus gradually undergoes
a series of changes, in volume, form, situation, and direction, a
knowledge of all which is highly important to the accoucheur.
These changes occur both in the neck, and in the body, each of
which I will review individually.

CHANGES EST THE NECK OF THE UTERUS. As gesta-
tion proceeds the congestion and ramollissement of the substance
of the cervix gradually advances, until finally the whole neck
becomes softened.

Toward the end of the first month, the lower or inferior portion of
the cervix commences to undergo this change, which is principally
confined to the mucous covering of the part, imparting to the
finger a fungous softness, but through which deeper pressure will
detect the firm consistency of the proper tissue. The softening
always commences below and advances upward, gradually progress-
ing, so that at the end of the third month, or commencement of
the fourth, this modification extends into the substance of the lips,
softening them through their whole thickness to the extent of a
line and a half, and increasing as gestation progresses, until at the
sixth month it embraces one-half of the vaginal projection of the neck.
It continues to advance gradually upward during the last three
months, until finally the whole cervix, together with the ring of the
internal orifice becomes so softened, that at " term" it has occa-
sioned, in the practice of the inexperienced physician, much difficulty
in discriminating it from the vaginal walls.

This ramollissement of the neck is an important indication of
pregnancy, being present at an early period, and is found in all
females in whom the neck is in a normal condition ; it likewise
renders material assistance in determining the stage of pregnancy.
But in the investigation of this last point, it must always be recol-
lected that in females who have given birth to a number of
children, the vaginal projection of the neck loses a considerable
portion of its length, and consequently, if one half of this pro-
jection has been lost, the softening will not commence in the
lower extremity of the remaining portion, until the period at
which it would have ensued, were the neck of its original extent,
or at a period proportioned to the amount of length which has

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AMERICAN ECLECTIC OBSTETRICS.

been lost. Thus, in a woman who has given birth to eight or ten
children, the neck will vary very much in the extent of its soften-
ing at the sixth month, when compared with that of a female at
the same stage of gestation, who has borne only two or three
children. In primipara?, or women with their first child, this soft-
ening progresses more slowly thau in multipara?, or women who
have previously had children.

Beside the softening of the neck, it undergoes other modifica-
tions. During the early months of pregnancy it becomes thicker,
with an increase of its volume, more especially at its superior por-
tion; it is also found at a lower point within the vagina, inclined
a little to the left, with the os tinea? looking more toward the pubis,
and, as a larger extent of it can now be felt and examined by the
finger, it has given rise to an erroneous impression that its length
was likewise increased. At the fifth month the cervix looks more
toward the sacrum, and still a little to the left, becomes more
elevated and is difficult to reach ; this elevation of the neck grad-
ually increases as pregnancy advances, rendering it more and more
difficult to reach, and which has, probably, led to the mistaken
views of several authors, that the cervix became gradually short-
ened from the fifth month until "term," at which period it was
completely effaced. The fact is, however, that there is no short-
ening of the neck until the ramollissement has occupied its whole
extent, rendering it yielding and incapable ot resistance, which
generally commences in the last fortnight of pregnancy, and during
the last few days, both in primipara? and multipara?, its length
diminishes very rapidly, resulting in its entire disappearance. As
the neck ascends, looking backward and to the left, the fundus is
nearly always carried forward and to the right.

Perhaps, it would be proper to remark, that in primipara?,
toward the seventh month, there exists a slight diminution of the
length of the cervix, but which does not materially affect the cor-
rectness of the above statement; this shortening is occasioned by
the spindle shape assumed by the cervix at this period, or a bulg-
ing of its central part, which necessarily causes a slight approxi-
mation of the external and internal orifices of the neck. This
does not happen in multipara?.

The form of the cervix is different in primipara? and multipara?,
during gestation. Among the former it will be found more pointed
and contracted at its inferior extremity, and enlarged at its superior
and the os tinea? changes from a hardly perceptible transverse

CHANGES IN THE UTErtUS DURING PREGNANCY.

119

fissure, to one of a circular form, though it is seldom, if ever,
opened, until dilatation occurs during labor. About the seventh
month, the walls of the neck having become softened, they readily
yield to the pressure of the secretions from their internal surface,
and as the os tincse remains closed, the central portion of the canal
of the cervix is pressed outward, which gives to the whole neck a
fusiform appearance. The external surface remains smooth and
polished, and the os tineas regular and rounded, without any rough-
ness or inequalities; the circumference is sometimes soft, and
occasionally, during the latter months, presents a sharp and thin
border. Among multipart, the form of the cervix is quite dif-
ferent, somewhat resembling a thimble, with its small extremity
upward, its orifice instead of being closed is opened sufficiently to
admit the extremity of the finger, and its periphery is very irreg-
ular on account of numerous cicatrizations and fissures, the results
of previous lacerations. As the softening advances upward, the
opening of the os tincse and inferior portion of the cavity of the
neck" simultaneously continues to increase, so that each month the
finger may penetrate deeper into this thimble-shaped, and some-
times funnel-shaped cavity. Toward the ninth month, the second
phalanx of the finger can be introduced within this opening, its
free extremity being arrested by the closed and puckered ring at
the internal orifice, which finally softens and dilates, allowing the
finger to pass through the cavity of the neck, and to come in direct
contact with the membranes. At this period the canal through
which the finger passes, insl ead of being shortened, will be found to
vary from one inch, to an inch and a half in length. {Figs. 25, 26, 27.)

Fig. 25. Fig. 26. Fig. 27.

These 1'igurea show the softening and opening of the cervix uteri, as pregnancy advances ; also, how
the finger ultimately gets into direct contact with the naked membranes.

The softening and spreading out of the neck is said to be greatly
accelerated by frequent touchings or examinations during preg-
nancy, and occasionally the internal orifice opens at too' early a

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period, even in the seventh month, especially among those women
who are subject to floodings.

It is sometimes the case, that the presenting part of the fetus, in
engaging in the excavation, presses the anterior inferior portion of
the uterus before it, which, in a large pelvis, may even descend to
the inferior floor, occasioning much embarrassment to the inexpe-
rienced practitioner, who not being able to ascertain the situation of
the os tincse, might erroneously suppose it to be imperforate. It
will be readily seen that, as the portion of the uterus mentioned is
pushed downward, the neck will be carried behind it, with the os
tincse looking toward the anterior face of the sacrum, and much
difiiculty may be experienced in gaining access to it; but when once
reached, the finger must be bent like a hook and introduced into its
cavity from behind directly forward, pulling the neck by its
anterior lip down toward its normal location at the center of the
cavity, while at the same time, efforts may be made with the other
hand on the abdomen, or by means of an assistant, to elevate or
push the body of the uterus upward and backward. While* the
womb remains in this mal-position, it will be impossible for delivery
to be accomplished until the above change in its direction is effected ;
and when efl'ected, if the female has been long in labor, with evident
symptoms of dangerous exhaustion, the os uteri soft and dilated or
dilatable, and the head at the superior strait, my own experience is in
favor of at once terminating the labor by turning and delivering by
the feet, at the same time administering sufficient stimuli to sustain
the sinking powers of the system. This is the course I have
adopted in three instances of similar character, and in each of which
success crowned my efforts, with the exception of one child being
still-born.

PHYSICAL CHANGES IN THE BODY OF THE UTERUS,
etc. In the non-gravid state, the uterus may be said to be in an
inactive or dormant condition, from which it is suddenly aroused
by conception, and becomes more susceptible, with increased tem-
perature and swelling, from the greater sanguineous determination
toward it. The volume of the uterine walls increases in every direc-
tion, and the uterine cavity enlarges, which enlargement is main-
tained by the new formation called the caducous membrane, and
which is present long before the impregnated ovum reaches the
uterine cavity. As soon as the ovule has reached the uterus, the
increase of volume or development of the embryo, continues and

CHANGES IN THE UTERUS DURING PREGNANCY.

121

progresses until the moment of parturition, being more rapid in the
latter than in the early months.

The shape of the uterus is not materially changed during the first
month of pregnancy, but subsequently, as its volume augments,
from being flattened from before backward, it gradually grows
rounder, assumes the shape of a pear, or gourd, then spheroidal,
until toward the termination of gestation, it becomes of an ovoid
form, slightly flattened in its antero-posterior diameter, with its-
auterior face more convex, and its posterior somewhat concave, to
adapt itself to the projection of the lumbar vertebra.

The situation of the uterus must necessarily vary in proportion to
its increasing size and shape; thus, we find that during the first
three months of pregnancy it is lower in the vagina, or pelvic
cavity, with the os tincae a little inclined to the left, and thrown
forward to the pubis ; but after this period it gradually rises from
the excavation into the abdominal cavity, pushing the opposing
contents of this cavity before it. From a knowledge of the various
points at which the fundus is located, we may be enabled to deter-
mine the period of gestation ; thus, at the fourth month, it will be
found two or three fingers' breadth above the pubis; at the fifth
month, it will be found within one finger's breadth of the umbilicus;
the hypogastrium projects and is rounded, the vagina is elongated
and narrowed, and the motions of the fetus are felt ; the cervix is
more elevated, is turned upwardly, and is more difficult to reach ;
from the fifth to the sixth month, the fuudus passes the umbilicus,
and, at the sixth month, is found half an inch above this depression,
which now begins to project beyond the integuments; the vagina
still further elongated and narrowed, with only a few projecting
wrinkles at its lower portion ; the cervix will be found nearly on a
level with the superior strait, softer and larger than previously;
ballottement is now readily effected ; at the seventh month the
fundus will be found three fingers' breadth above the umbilicus,
with increased abdominal and umbilical projection, and often pain
in the groins, from distension of the muscles of the abdomen ; the
neck is still further softened, more voluminous, and more difficult
to distinguish ; at the eighth mouth the fundus extends into the
epigastric region, the abdomen is further distended, and the skin
frequently cracks and presents livid marks or lines; the ramollisse-
ment, or softening of the cervix is still further advanced ; during
the ninth month, the fundus still continues to ascend, but in the last
fortnight of gestation, there is an evident depression of the abdom-
9

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AMERICAN ECLECTIC OBSTETRICS.

inal projection, the fundus is on a lower level than before; the
respiration becomes more free, the woman more lively, and expresses
herself as feeling lighter ; the cervix is entirely effaced. This sen-
sation of sinking of the womb, is, probably owing to descent of the
fetus the head of which can usually, at this period, be readily felt,
presenting a voluminous tumor within the pelvic excavation.

Although the above is the average of a number of observations,
yet they are not invariable ; as in many females, the shape and
capacity of the pelvis and abdomen, and the resistance of the abdo-
minal parietes, will affect, more or less, the rapidity and extension
of these changes.

The direction of the uterus is altered by the changes which take
place in the organ during pregnancy ; while it remains within the
excavation where it is supported by the pelvic bones, it holds its
vertical direction, but as it passes upward into the cavity of the
abdomen, where the soft parts alone sustain it, it inclines forward,
following the direction of the axis of the superior strait, and which
may be owing to the unyielding resistance of the lumbar promi-
nence, and the yielding of the anterior abdominal wall ; from the
same cause it is made to lean toward one side of the abdomen, most
commonly the right, forming the right lateral obliquity of the
uterus. The reason of the greater frequency of this right obliquity,
is, according to Mad. Boivin, that the round ligament of the right
side is shorter, stronger, and more abundantly supplied with mus-
cular fibers than the left; and as they draw the uterus toward the
right, they necessarily cause this organ to rotate on its axis, carry-
ing its anterior surface somewhat to the right side, and its posterior
to the left ; both of which changes are important to be understood.

The thickness of the uterine parietes has given rise to much contra-
dictory speculation; some writers concluding, that in consequence
of the great distension of the uterus, its walls become very much
attenuated, while others consider that they become very much
thicker during pregnancy ; but the fact is, that at the period of
parturition, if an examination of the uterine parietes be made, they
will be found to vary according to the portion examined, the neck
being very thin, and the body and fundus of the same thickness as
when in the non-gravid condition, with the exception of the part
corresponding to the insertion of the placenta, which is thicker
than at any other place. As there is, then, no diminution of the
uterine walls during gestation, there must necessarily be a great
augmentation of their bulk, which is ascertained to be the case, as

CIIANGES IN THE UTERUS DURING PREGNANCY.

123

at term, the uterus has been found to weigh two pounds ; and in
one instance, cited by M. Moreau, it reached nearly four pounds.
In a few rare instances, the parietes of this organ have been found
to be only a few lines in thickness.

The density of the uterine parietes likewise changes during gestation.
In the non-gravid condition they are hard, resisting, and of a con-
sistency approximating fibrous tissue, but in pregnancy they become
softer and relaxed, which condition is present even at the first
month, the walls, having a softness which gives a sensation on pres-
sure, similar to that of an cedematous limb, or of caoutchouc soft-
ened by boiling in water, and which is of some value in determining
pregnancy. As the parturient period approaches, this ramollisse-
ment and yielding character of the walls continue to increase, so
that the inequalities of the fetus may be felt through them, and its
motions may not only be distinctly perceived, but will often pro-
duce a momentary projection of some part of the organ, and even
of the abdominal parietes. In consequence of this suppleness of
the uterine fibers, the fetus can change its position within the
cavity of the organ during gestation, and thus cause its diameters
to vary according to the position assumed, shortening its normal
long diameter, and lengthening its short ones. The fetus is also
protected from the evil results of blows upon]the abdomen, or severe
shocks received by the mother, which would eusue were the walls'
more dense and unyielding.

VITAL CHANGES IN THE UTERINE TISSUES. The most
remarkable changes of the uterus, during pregnancy, are those
effected in its texture, especially that of its proper tissue, or middle
coat. This tissue, which, as I have heretofore remarked, is of a
grayish color, dense, and composed of fibers of an obscure character
in the non-gravid womb, in pregnancy manifests its true nature*,
changing from a state of density to one of softness and elasticity,
extending its substance, enlarging, gradually assuming a reddish
hue, having its fibers gradually unfolded, elongated, and presenting
unequivocal evidence of its muscular nature.

Although the muscular character of the middle uterine coat has
been determined, yet the arrangement of its fibers is still involved in
uncertainty. Mad. Boivin, who has minutely examined the uter-
ine structure, has probably given us the most correct account of
the disposition of some of these fibers ; still, there is much left to
ascertain on this point. She states, that there is an exterior plane

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AMERICAN ECLECTIC OBSTETRICS.

of fibers, running or radiating from the middle line, outward and
downward, to the lower third of the womb ; upon this part they
terminate, and aid in forming the round ligaments located there,
while the most superior ones are distributed to the Fallopian tubes,
and the ovarian ligaments. There is also an internal plane of fibers,
the arrangement of which varies considerable from the external, in
being circular, and located at the uterine superior angle; having
the internal orifice of the tubes as their center, they surround each
of them, describing concentric circles, being very small and close
toward their focus, but gradually separating as they advance from
this point, so that the last and largest are found upon the median
line, and extend in the direction of its length. Other muscular
fibers are found between these two planes, but they can not be
traced. At the inferior part of the organ is a semicircular order of
fibers, which commence at the median line of this region, and
reunite on the sides near the round ligaments.

This structure of the uterus resembles that of all hollow organs,
having longitudinal fibers externally, and circular and horizontal
ones internally. The greatest development of muscular structure
is found in the fundus, which is the part of the organ more espe-
cially concerned in the expulsion of its contents, and this struc-
ture is so disposed that, during contraction, the uterine surface
approaches toward the center. The least resistance, during labor,
should be made at the inferior part of the uterus, in which we find
merely the horizontal fibers, forming an arrangement which will
bear some comparison to a sphincter muscle.

Other anatomists have attempted to trace the uterine muscular
fibers, and have separated them into layers, planes, and fasciculi;
yet, notwithstanding all these attempts, there is so much irregu-
larity and confusion in the course and arrangement of these fibers,
bo many crossings and intercrossings, and such an interweaving of
them, that it is impossible to demonstrate them satisfactorily; we
have presented to us only an inextricable muscular network, render-
ing the uterus fully capable of performing all its various movements
of extension, contraction, dilatation, and shortening. M. Moreau
observes, that "a skillful dissector may give the fibers any direction
he chooses, without the possibility of proving the contrary."

That the longitudinal and horizontal fibers are separate and inde-
pendent parts of the uterine structure, and probably all the other
fibrous arrangements, may be inferred from the fact, that we often
have one set of them powerfully acting, while, at the same time, the

CHANGES IN THE UTERUS DURING PREGNANCY.

125

other is contracting with but slight force, or even not at all. Thus,
in the hour-glass contraction, we have an example of forcible con-
traction, and a want of it at the two antipodal extremities. Again,
not unfrequently there appears to be a want of action of those fibers
which contract the organ in its longitudinal diameter, elongating the
uterus to such an extent, that, as ascertained by an examination through
the relaxed abdominal walls, after delivery, its length will be ten or
eleven inches, with the fundus elevated toward the epigastrium,
while its transverse diameter will be only three or four inches,
resembling an intestine, rather than the womb.

A female during labor, as is often the case, may suffer intense
pains, and make the most vigorous efforts, without any advance,
whatever of the child, although the pelvic formation is normal, and
the uterus sufficiently dilated ; may this not be owing to a want of
simultaneous action of the two separate sets of fibers, the horizontal
being active, while the longitudinal are slightly so, or altogether
inert? This want of synchronism in the movements of the fibers,
may be owing to irritation occasioned by protracted or severe labor,
by rheumatism, by the administration of ergot, or by officious inter-
meddlings, and which may also result from extreme susceptibility of
the nervous system. In either case, to relieve this painful condition,
a laxative injection should be administered, with the internal use of
Opium, Morphia, Diaphoretic powder, or, still better, the compound
pill of Black Cohosh [Am. Dispensatory], which may be given, as
often as the urgency of the symptoms indicate; the room must be
freely ventilated, the drinks should be cool, and no examinations per
vaginam must be instituted until the contractions become normal,
and not then, without they are actually necessary. Occasionally,
under these circumstances, and where there have been no previous
violent contractions, in addition to the above treatment, I have
found firm, but moderate pressure over the fundus to restore the
energy of the inactive fibers.

The serous, or external peritoneal coat of the uterus, during preg-
nancy, extends in every direction, with a more active nutrition that
prevents any diminution of its depth, there being but little difference
in the thickness of this external covering, either in the gravid cjr
non -gravid womb. The serous covering is movable on the tissue
which unites it to the middle or muscular coat, this tissue being
apparently diminished in density.

The internal, or mucous coat of the uterus, about which there
have been so many discordant opinions, becomes very evident during

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AMERICAN ECLECTIC OBSTETRICS.

pregnancy; it presents an increased and villous appearance, and
from its great development its nutrition undoubtedly becomes more
active. Its follicles become more marked, with an increase of their
secretion. There are also glands found imbedded in the thickness
of this coat, which appear to enter into the internal muscular layers;
these enlarge after conception, and are viewed by some authors as
the principal elements of the caducous membrane. These glands
resemble small canals, and run tortuously within and behind the
mucous uterine coat, forming a kind of knot, throwing out ramifi-
cations, and opening on the internal face of the inner mucous layer;
they have been called the utricular glands.

The bloodvessels of the uterus likewise undergo changes which
may be briefly noticed. In the unimpregnated condition the arte-
ries are small, flexuous, and very much contracted, but during ges-
tation, as they become less compressed by the uterine fibers, they
expand, soften, and describe more regular curves ; their caliber
increases, the blood circulates more largely and rapidly, and a more
active and energetic nutrition ensues. The arteries of the uterus,
as heretofore stated, are furnished by the spermatics and hypogas-
trics, the superior portion of the uterus receiving chiefly the
branches from the spermatics, and the body and cervix those only
from the hypogastrics. The arteries are always tortuous, and when
they arrive at the uterus, they do not run any distance under the
peritoneum, but immediately enter into the muscular coat, pass
toward the inner surface, and especially to the part where the pla-
centa is attached, ramifying and anastomosing freely as they pro-
ceed; those branches which reach the lining membrane terminate
in the tortuous canals in the placental decidua, while those which
do not arrive at the inner surface ramify upon the coats of the
veins. The veins of the uterus are greatly dilated, much more so
than the arteries, and their points of communication with each
other are multiplied to that degree, that at the parturient term, an
inextricable mass of venous vessels is presented, giving to the
uterine tissue a resemblance to that of the erectile. That part of
the uterus to which the placenta is attached is more abundantly
supplied with veins ; and on removing the placenta the veins which
open into the uterine cavity will be seen, presenting large, smooth-
edged and oblique apertures. There are no proper valves to the
veins, so that if any fluid be injected into the trunks of the speiv
matic and hypogastric veins, it will flow in a full stream into the
cavity of the uterus, which may afford some explanation of the caus e

CHANGES IN THE UTERUS DURING PREGNANCY.

127

of the large, quantity of blood discharged in so'short a time from
the uterus during parturition, together with that from the exposed
arteries. The venous circulation in the uterus and placenta may be
readity interrupted by the various derangements of function in the
thoracic and abdominal viscera, and the removal of these obstruc-
tions during pregnancy is an important point.

The lymphatic vessels, or absorbents, likewise, become greatly
enlarged during pregnancy : according to Cruikshank, the first who
observed them, they are as large as a goosequill, and are so numer-
ous, that when injected with mercury, they give to the uterus the
appearance of a mass of lymphatic vessels. Those of the neck run
into the pelvic ganglia, and those of the body into the lumbar
ganglia. Cruikshank supposed their function to be that of carry-
ing on a " copious absorption in the uterus toward the mother,"
duriug pregnancy ; but Dr. Robert Lee has suggested another very
probable function ; he observes, " The sudden removal of the uterine
structures after delivery, by absorption, is probably the most
important office they perform, and the cause of their enlargement
to such a vast size during the latter months of pregnancy."

The nerves of the uterus likewise become considerably developed
duriug gestation, for the undoubted purpose of furnishing the uterus,
during the parturient act, with all the nervous energy that may be
necessary. After delivery, the nerves, together with all the aug-
mented tissues and vessels of the uterus, return to their original
size and condition.

CHANGES EST THE PROPERTIES OF THE UTERUS. In
the un impregnated condition, the vital properties of the uterus are
very obscure, so that it may be touched, compressed, pricked, or even
cauterized without causing pain or much uneasiness, unless it be
morbidly affected ; at this time its properties are chiefly limited to
its tonic forces, or organic sensibility and insensible contractility,
the separation of the principles of growth and nutrition from the
circulating fluids, and the elimination of de- vitalized or decomposed
elements which are no longer necessary to the maintenance of life.

It is true, that when the finger is brought into contact Math the
neck, the female is conscious of the touch ; however, the sensation
goes no farther; but during pregnancy the animal sensibility becomes
much more marked, and the female more readily recognizes the con-
tact of bodies with the neck, as well as the fetal movements, and which
sensibility becomes more developed as gestation advances, so that in

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AMERICAN ECLECTIC OBSTETRICS.

its latter stages even the touch becomes excessively painful with
many women, and during parturition the uterine contractions pro-
duce intense agony. The introduction of the hand within the
uteius, for the purpose of turning, effects similar pain, and when
the adhering placenta is removed artifically, the woman experiences
sensations as if she were being eviscerated. This exaltation of ani-
mal sensibility is principally confined to the neck, the body of the
organ being nearly insensible; there exists, however, a relation
between these two parts, from which irritation of the neck will
influence the fibers of the body. And this relation will account
for the premature births effected by repeated touchings, frequent
coition, the irritations of the cervix from artificial dilatation, or
the use of agents which stimulate the cerebro-spinal system.
It occasionally happens, that the female will be unconscious of any
movements of the fetus until the latter months of gestation, or even
not until labor actually commences, owing to the slight development
of sensibility, but in the majority of cases it is the very reverse of this.

The most remarkable property, however, which the uterus man-
ifests during pregnancy is its organic contractility, which either did
not previously exist, or if it did, it remained latent. This prop-
erty, precisely resembles the contraction of a muscle, and is never
manifested except under some irritating or stimulating influence;
it varies in intensity in different females, and is so marked and
energetic in many instances as to benumb the hand of the strong-
est man, when introduced to perform artificial delivery. It is this
contractile power which effects the expulsion of the fetus and its
secundines, as well as other productions which maybe accidentally
developed within the uterine cavity, and which, likewise, causes
the womb, as well as its various vessels, to gradually return to the
diminished condition in which they were previous to conception.
Should the organic contractility of the uterus, from any cause, fail
to manifest itself after parturition, a hemorrhage would ensue that
would prove rapidly fatal to the parturient woman ; and, when
such cases occur in practice, the most important indication is to
arouse this power of contraction, which is the natural remedy, and
which produces its beneficial results by closing and obliterating the
large open mouths of the bloodvessels on the internal placental
surface of the organ.

In the human family the presence of these contractions is always
accompanied with more or less pain, which is never found among
animals in a state of nature, and which exists among savages and

CHANGES IN THE UTERUS DURING PREGNANCY.

129

domesticated animals in only a minor degree. Accident or disease
may, however, be the cause of pain with these last when in labor;
and we have good reasons for believing that the excessive pains
undergone by parturient females of our own race, are the results
of the enervating influences of civilization and its various customs,
habits, and refinements upon the constitution. In 1842, I was

called upon to attend Mrs. D , about twenty years of age, a

short, thick-set female, brunette, and in apparent good health, with
her first child; there had been observed a discharge of the waters,
"the show," together with some singular and indescribable feel-
ings, but no pain. From these symptoms, together with the calcu-
lations made upon the matter, it was presumed that labor could
not be far distant; and it was, likewise, deemed expedient by the
mother that the advice of a physician should be resorted to. Hav-
ing ascertained that no pains of any kind had been experienced, I
thought myself unwarranted in making any examination, but did
so at the urgent request of the mother, when to my great aston-
ishment I found the head within the pelvic cavity, and upon
placing my hand upon the abdomen, I felt very distinctly the con-
tractions of the uterus as they occurred, but the patient com-
plained of no pain whatever. I now seated myself by the bedside
to watch the progress of labor, as well as to be ready for any
emergeucy in so singular a case, and the whole process of parturi-
tion was effected without any untoward accident, and without the
least pain, if the asseverations of the female are to be believed;
during the latter stage she evidently contracted the abdominal
muscles and made bearing down efforts, not, she stated, from any
painful influences, but from a strong sensation or desire to make
them. Shortly previous to my visiting the West, I again attended
this lady in her second labor, when she suffered as severe pains as
I remember to have ever witnessed in the parturient chamber.
The cause of this anomaly I do not pretend to understand; it has
always been a matter of much wonderment to me, and I am not
aware whether a similar circumstance is on record in the annals of
midwifery.*

*In the course of some conversation with Prof. Powell, on medical subjects in gen-
eral, I stated this case to him. He immediately asked me, whether she complained of
pain, or soreness, at the junction of the neck with the cerebellum; which brought to
my recollection the fact that she did; but, at that time I did not suspect that there was
any connection between the uterus and the cerebellum, and therefore I was not suffi-
ciently impressed with the importance of it, to investigate its particulars.

i.

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AMERICAN ECLECTIC OBSTETRICS.

The exercise of these organic contractions ensues involuntarily
and without any dependence on the will, yet we sometimes find
them influenced by mental impressions, so much so, that a violent
emotion may arouse them at a premature period, and it is not an
uncommon circumstance for the appearance of the accoucheur in
the room of the lying-in woman to cause a suspension of them for
several hours, or even days. They may likewise be suspended for
some hours, by the administration of opiates, as well as excited by
stimulants, or irritation applied to the neck, or, ergot, strychnia,
electricity, borax, and many other agents internally administered.
If the uterus is excessively distended — if the labor has been too
rapid, or prolonged, the contractions are very apt to diminish —
become more slow and feeble — or entirely cease. I have met with
instances, in which the contractions have been suspended for sev-
eral hours, in consequence of an intoxicating draught of hot gin
or brandy sling having been given by the nurse, to " ease the
pains and give the woman strength."

He locates an organ of Animal Sensibility immediately behind the mastoid process
in the cerebellum, and in support of its existence and influence, he recited several
interesting pathological cases, from which I select the following.

A boy had considerable pain and soreness in the right organ of Animal Sensibility;
that is, he complained of pain in that part, and soreness of the soft parts, external to
it. During his acquaintance with this boy, which was only a few months, he occa-
sionally became paralytic as to sensation, on the left side, the skin could be cut or
pinched, on that side, without his knowledge of it.

He stated another case, of a man who had an exceeding tenderness of the part indi-
cated by the location of the organ of Animal Sensibility, with an exceedingly acute
sensibility of the cutaneous surface of the opposite side; he could not bear the contact
of his clothes upon it.

But a more important case to the practical wants of the profession, though it does •
not directly illustrate the case before us, is the following. He was called to see a lady
who had, two weeks previously, been delivered of her first child. In consequence of the
number of persons present, and other circumstances, he could not ask her any private
questions. Her complaint was a severe pain on the median line, or rather to the right
of it, at the top of the neck, answering to the location which he assigns to the organ of
Amativeness. She had no soreness in the part. He drew the conclusion, that the pain
was symptomatic of a diseased condition of the left ovarium. The facts, as subsequently
ascertained, proved his diagnosis to be correct. He added, that if she had complained
of any soreness over the painful part, he would have concluded, that that portion of the
cerebellum was diseased.

It is possible, in view of these facts, that the peculiarity of the case before us, may
have been occasioned by some deranged condition of a portion of the cerebellum. This
is the opinion of Prof. Powell, whose authority, on a question of this kind, is entitled to
some attention.

CHANGES IN THE UTERUS DURING PREGNANCY.

131

These changes in the condition of the uterus, necessarily effect
some modifications of the neighboring parts. In the early period
of pregnancy as the uterus enlarges in the cavity, the vagina
becomes shortened, but as soon as the former rises above the
superior strait, the latter becomes narrower and longer; in its ele-
vation the uterus carries its surrounding peritoneum along with it,
the folds of which, or the broad ligaments disappear, and the
tubes and ovaries approach nearer to the uterus, where they rest,
nearly in a perpendicular position ; the round ligaments present
short linear fibers, among which are prolongations of the muscular
fibers of the uterus, and which contract with that organ.

From the increased vitality of the reproductive organs, as well
as from the obstruction of circulation by the enlarged uterus, the
veins of the vaginal walls become more developed, with various
appearances, which are often recognized toward the termination of
gestation, by the finger. The vaginal pulse, of Osiander, which he
estimated highly as a diagnostic sign of pregnancy, may be felt,
at some portion of the vagina, and is owing to the excessive
enlargement of the vaginal and uterine arteries. About the seventh
or eighth month, the vaginal mucous membrane is frequently cov-
ered with granulations the size of a pin's head, which not only
line the whole extent of this canal, but also the exterior surface of
the neck, and even the interior. When these are present there is
an increased vaginal secretion.

One of the important changes to bo understood by the practi-
tioner, is that undergone by the bladder. This organ is gradually
pressed above the superior strait, the urethral canal is elongated,
and its orifice will be found behind the edge of the pubic symphy-
sis, so that in introducing a catheter it must be directed nearly if
not quite parallel with the pubic bone, with its concavity in front,
and, in some instances, the curve of the canal becomes so great,
from the bladder being pressed forward and above the pubis, that
a male catheter will be introduced with more facility. This com-
pression on the upper part of the canal, impedes the circulation in
the lower parts, from which results tumefaction of its whole length.
Tenesmus of the bladder is often the consequence of compression
on the body and neck of this organ, occasioning frequent, urgent,
and ineffectual efforts to urinate. In not a few instances the cathe-
ter will have to be used to relieve the irritated and distended
bladder.

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AMERICAN ECLECTIC OBSTETRICS.

SYNOPSIS OF THE SIGNS OF PREGNANCY AT DIFFERENT STAGES.
During the First and and Second Months.

RATIONAL SIGNS. SENSIBLE SIGNS.

1. Suppression of the catamenial dis-
charge.

2. Nausea, vomiting, ptyalism, anor-
exia, etc.

3. Unnatural flatness oyer the hypogas-
trium.

4. Tumefaction and tenderness of the
mammae.

1. Increase in the size and weight of the
uterus, with slight prolapsus. The cervix
uteri is directed to the left and toward the
symphysis pubis.

2. Diminished mobility of the uterus, its
walls soft like caoutchouc.

3. The os uteri round and regular in
primiparae, but in multipara, irregular in
its circumference and more or less open.

4. Ramollissement and apparent oedema
of the mucous membrane, covering the
lips of the cervix uteri. The fibers of the
neck not yet softened.

During the Third and Fourth Months.

1. Suppression of the catamenia, (an oc-
casional exception).

2. Continuance of nausea, vomiting, an-
orexia, ptyalism.

3. Slight prominence over the hypogas-
trium.

4. Depression of the umbilicus.

5. Tumefaction of the breasts increased,
with prominence of the nipple, and a
Blight discoloration of the areolae.

6. Kiesteine in the urine.

1. The fundus uteri elevated rather
above the superior strait, at the end of the
third month. At the termination of the
fourth month, it rises two or two and a
half inches above the pubis.

2. Fullness, and dullness on percussion
over the hypogastrium.

3. Existence of a small tumor in the
hypogastric region, detected by abdominal
palpation, about the size of a child's
head a year old.

4. The direction of the long diameter of
the uterus is now changed, so as to corres-
pond with the axis of the superior strait.
At the fourth month the os uteri is consid-
erably elevated in the excavation, looking
backward and to the left.

5. Ramollissement of the inferior por-
tion of the cervix is more marked ; os uteri
more open in the multiparae, but still
closed and rounded in those who have not
borne children.

During the Fifth and Sixth Months.

1. Suppression of the catamenia. (Some 1. At the end of the fifth month, the
rare exceptions.) fundus uteri is within an inch of the um-

2. Cessation of nausea, vomiting, etc., bilicus, and the same distance above it at
now usually takes place, though they may the sixth.

continue throughout pregancy.' 2. Movement of the fetus is now active.

CHANGES IN THE UTERUS DURING PREGNANCY.

133

RATIONAL SIGNS.

3. Increased prominence of the sub-um-
bilical region.

4. The size of the abdominal tumor is
increased, it is round, elastic, and if the
abdominal walls be thin, the inequalities
of the fetus may be felt.

5. The umbilical depression nearly ef-
faced.

6. Discoloration of the areolae more
marked, with an enlargement of the sub-
cutaneous glands.

7. Kiesteine in the urine.

SENSIBLE SIGNS.

3. The bruit de souffle and the fetal pul-
sations may now be distinguished.

4. Ballottement.

5. Between the cervix and the pubis a
tumor may now be felt, either soft and
fluctuating, or round, hard, and resisting.

6. Ramollissement of the inferior half
of the cervix uteri.

7. In the primiparse, the os uteri is still
closed, but in the multiparas, it is suffi-
ciently open to admit the half of the first
phalangeal bone, although in each it is
softened to the same extent.

During the Seventh and Eighth Months.

1. Suppression of the catamenia.

2. Naussa, vomiting, etc., ordinarily ab-
sent.

3. Abdominal tumor much increased in
size.

4. Dilatation of the umbilical ring, and
pouting of the navel.

5. Increased discoloration of the areolae,
with enlargement of the sebaceous follicles,
and increased prominence of the nipple.
The milk may be pressed from the swollen
mammae.

6. Discolorations on the skin of the ab-
domen.

7. Vaginal-granulations.

8. Kiesteine still exists in the urine.

1. Increased size of the abdomen.

2. The fundus uteri, at the end of the
seventh month, has risen two and a half
inches above the umbilicus; at the eighth,
it is placed within the epigastric region ;
uterus commonly inclined to the right.

3. Movements of the fetus become more
violent.

4. The fetal pulsations and the bruit de
souffle still continue.

5. Ballottement perfectly felt during the
seventh month, but becomes obscure in the
subsequent months of pregnancy, on ac-
count of the increase in the size of the
fetus.

6. The ramollissement of the cervix is
more extensive, and at the end of the
eighth month is nearly complete.

7. In the primiparae, the cervix is ovoid
and somewhat shortened; the os uteri is
still closed.

8. In the multiparae, the os uteri is co-
noidal and wide enough open to admit the
whole of the first phalangeal bone ; the su-
perior fourth of the neck still hard and
firmly closed.

During the First Half of the Ninth Month.

1. Reappearance of vomiting, not from 1. The fundus uteri occupies the epigas-
nausea but from pressure of the gravid trie region.

uterus against the stomach. 2. The movements of the fetus ; the pul-

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AMERICAN ECLECTIC OBSTETRICS.

RATIONAL SIGNS.

2. The abdominal tumor is increased in
size; skin much stretched and tense.

3. Respiration difficult.

4. All the other symptoms remain and
are augmented in intensity.

SENSiBLE SIGNS.

sation of the fetal heart and bruit de souf-
fle are still present. At this time ballotte-
ment has disappeared.

3. The whole cervix uteri is softened, ex-
cept the internal orifice, which remains
firm and closed. The os uteri in primi-
parse is slightly opened, though not suffi-
ciently to admit the finger, as is the case
in multiparas, although the softening is
equally extensive in each.

During the Last Half of the Ninth Month.

1. The vomiting ceases, as the abdominal 1. The fundus uteri has sunk low down
tumor sinks from the epigastrium. in the abdomen.

2. Respiration less oppressed. 2. The sensible signs still persist, except

3. Considerable difficulty exists in walk- ballottement, which is usually, though not
ing, owing to the sinking of the presenting always, absent after the fetus has acquired
part into the pelvic excavation. considerable size.

4. Constant and ineffectual desire to 3. In multiparas, the internal orifice of
evacuate the bladder and rectum. the cervix is softened and dilated, so that

5. The hemorrhoids, the oedema of the the membranes may be felt. In the primi-
limbs and the varicose condition of the parse, the internal orifice is soft and di-
veins of the inferior extremities are all lated, but the external remains partially
increased. closed. During the last ten or twelve days,

6. Pains in the loins, and colics. owing to the dilatation of the internal

orifice of the cervix uteri, the whole cavity
of the neck becomes enlarged, so as to
increase the size of the uterine cavity ; so
that in touching, the finger reaches the mem-
branes, in the primiparae, after having
passed the thin and even margin of the os
uteri. While in the multiparae, this margin
is thick and unequal.

CHAPTEE XVI.

COMPOUND AND MIXED PREGNANCY.

Compound or multiple pregnancy, are the terms applied to those
pregnancies in which more than one fetus exists within the uterus
at the same time. The cause of this peculiar disposition with some
women to compound pregnancies, is a matter of mere conjecture,
and but little is known relative to it which is either satisfactory or
worthy of confidence. It has been attributed to the impregnation

COMPOUND, AND MIXED PREGNANCY.

135

of two or more Graafian vesicles during a fruitful embrace, and
which may happen either in one or both ovaries ; again, and with
some degree of probability, it is stated that one vesicle may contain
two or more ovules, each of which becomes fecundated upon the
rupture of the vesicle during copulation. By some physiologists it
has been supposed that this anomaly is not the result of one act of
impregnation but of two or more, and this is undoubtedly true in
many instances, as examples are on record of females having given
birth to twins, one being white and the other colored, the result of
intercourse successively with a white man and a negro. And pre-
vious to the secretion of the mucus which fills the canal of the
cervix during gestation, or to the appearance of the coagulable
lymph which eventuates in the membrana decidua, superfetation
may be possible.

Cases of a marvelous and probably fabulous character, are
recorded where women have given birth to five, six, and even nine
children at one birth, but it is rarely the case that more than two
are present during pregnancy. In the course of a practice of
twenty-one years, I have met with but two cases of triplets, and one
in which a woman had four children at one birth, all closely resem-
bling each other ; while of twins or couplets I have met with quite
a number, averaging about one in every eighty labors. From the
want of sufficient vital force bestowed upon them, triplets seldom
attain adult age, and twins rarely attain the meridian period of
manhood.

As a general thing, in compound pregnancies, each fetus or
embryo is surrounded by its own proper membranes, the chorion
and amnion, so that the children do not come in contact with each
other; but have between them four layers or laminae, the two
amnios, and the two chorions which touch each other. Sometimes,
one chorion incloses both ovules, each, however, being enveloped
with its proper amnion, and in which case there are but two layers
or laminae separating them, the two amnios which rest against each
other. Occasionally, the fetuses are all inclosed in one amniotic
cavity ; and very rarely, one fetus is contained within the body of
another.

In the first-mentioned variety, should the placentas be united,
there will be no vascular communication between them: and should
one child die while within the uterus, it will not necessarily involve
the life of the other ; this will frequently be found to occur in twin
and triple pregnancies. The same labor may expel both children,

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AMERICAN ECLECTIC OBSTETRICS.

or, if permitted, one child may be born two or three days earlier
than its brother.

In the second variety, the chorion being common to each, there
will be two cords and but one placenta, and as in the first, one fetus
may continue to live independent of the death of the other. In this
variety the birth of the two children must take place during one
labor, the one being immediately expelled after the other.

In the third variety, one placenta will be common to each, with
two cords, which sometimes extend to the placenta, and at others
bifurcate from one common trunk at various distances from the
placenta. In these cases, we often meet, with monstrosities or
imperfectly-formed children. The birth of the children must take
place in this as in the second variety, during one labor; and pos-
sibly, the death of one may endanger the life of the other.

In the last form, monstrosity is the result. One fetus may be
inclosed in the abdominal cavity of the other, which is termed pro-
found, or abdominal inclusion; or, it may be merely surrounded by
the integuments of the other, forming an external tumor having no
communication with its internal cavities, which is termed the cuta-
neous or exterior inclusion.

There are no positive signs by which we can indicate the existence
of twin pregnancy, although some have been noticed by writers.
Thus, an unusual development of the uterus — but this may be owing
to an increase of the liquor amnii ; a flattening or longitudinal
depression of the abdomen on the median line, in connection with
the above, might justly give rise to a suspicion of twins, but this
could only happen when the fetuses lie one upon each side of the
uterus; two distinct shocks or motions, are sometimes felt at the
same time in different parts of the uterus, but no reliance can be
placed upon this as a sign; again, ballottement is exceedingly Jiffi-
cult in compound pregnancies, as one child must necessarily inter-
fere with the ascent of the other. Auscultation has been named as
a mode of detecting twin pregnancies, but we may err even in this,
as the sound of the fetal heart can often be distinctly heard in distant
parts, Cazeaux says, " Whenever the pulsations are heard at two
distant points, the line between these should be carefully sounded
with the instrument; for if they are produced by the presence of
two fetuses, the pulsations will become feeble, or almost disappear
toward the center of this line; but if, on the contrary, they are due
to a single child, they will be just as strong at its middle part as at
either extremity." However, it is of little importance to determine «

COMPOUND, AND MIXED PKEONANCY.

137

the presence of more than one fetus within the uterus during gesta-
tion, as a knowledge of it could be of no utility whatever, until
parturition had taken place, at which time it can readily be detected.

Compound pregnancy, in consequence of the excessive develop-
ment of the uterus, frequently induces labor previous to full term,
and it is not uncommon in these instances to find the uterus con-
tracting and expelling its contents during the seventh and eighth
months of utero-gestation.

In addition to the above there are, 1st, false pregnancies, improp-
erly so called, in which the uterus contains a false germ, mole, or
hydatids; and 2d, mixed -pregnancies, where the uterus contains both
a fetus and mole.

Moles and hydatid formations, are undoubtedly the results of some
diseased condition of the ovum, by which it becomes destroyed, or
metamorphosed, into a growth possessing sufficient vitality to exist
and augment in size, until removed by the uterine contractions. It
is a true conception at first, but which becomes blighted by disease,
and degenerates into a morbid development. These false pregnan-
cies are extremely difficult to detect. When the uterus increases
in size with greater rapidity than is natural under ordinary causes,
with nausea, or vomiting, great constitutional irritability, occasional
attacks of uterine hemorrhage, emaciation, quick pulse, etc., we may
be led to suspect the presence of hydatids; and upon a vaginal
examination, if we find a soft mass in the cervix, which upon being
roughly pressed, bleeds, and discharges upon the finger portions of
aqueous vesicles, our suspicion becomes certainty. Under these
circumstances we must endeavor to promote an early expulsion of
them. The index finger may be passed within the os uteri suffi-
ciently far to reach the mass and break it in pieces ; as soon as the
contractions of the uterus have removed the detached pieces, we
must examine again to ascertain whether any portion remains, and
if any are found, they must be again broken, and thus proceed till
the whole mass is discharged. If the finger can not be readily
introduced for the above purpose, a sponge-tent may be placed in
the canal of the cervix for the purpose of inducing uterine con-
tractions, or ergot may be administered.

Hemorrhage to an alarming extent often accompanies a labor for
the expulsion of hydatids, for which, in the early months, the
tampon may be employed, together with other means for arresting
» uterine hemorrhage referred to under the head of abortion.
10

138

AMERICAN ECLECTIC OBSTETRICS.

Mixed pregnancies are likewise very difficult to distinguish, and
are almost always a cause of abortion, at which time, the practi-
tioner must be Avatehful of the hemorrhage which may ensue.

When the ovule becomes impregnated within the ovary, it is
seized upon by the fimbriated extremity of the Fallopian tube,
through the canal of which it passes until it enters the cavity of the
uterus, in which it becomes gradually and fully developed. Many
writers believe that fecundation takes place only within the uterus,
but the existence of extra-uterine pregnancies proves that concep-
tion may ensue in the ovary itself; and the idea advanced by some
that the ovule after impregnation may make a retrograde move-
ment from the the uterine cavity through the tubes to the ovarj7 or
abdomen, is both absurd and opposed to reason. Undoubtedly con-
ception may take place in the ovary, tubes, or within the uterus,
whenever the the male semen comes in contact with the matured
ovum at any of its various points of discharge. However, let con-
ception occur where it may, it is occasionally found that the ovum
does not reach the uterine cavity, but is arrested or diverted from
its route, and attaches itself upon some unnatural point, from Avhich
it proceeds toward a partial development ; these instances are termed
abnormal, or extra-uterine 'pregnancies.

The causes of extra-uterine pregnancy are involved in much obscu-
rity; in some instances there have been found partial or complete
obliteration of the canal of the tubes, either at some particular point,
or throughout their whole extent, but the occasion of these closures
or their period of occurrence, is not satisfactorily explained. Blows
upon the hypogastrium soon after conception, have been named
among the causes, though there is no certainty in relation to the
subject, which is still one of inquiry. Cases are recorded in which
fecundation took place, although the tubal canals were imper-
forate throughout, and many others where it has occurred, with-
out a rupture of the hymen, so that notwithstanding what has
been advanced in relation to the matter of impregnation, much yet
remains for investigation.

We may be led to suspect the presence of extra-uterine pregnancy,
when we discover a premature enlargement of the abdomen above
the symphysis pubis — when this enlargement is less uniformly
developed, and more irregular in its shape, than in normal pregnan-
cies— when the tumor or enlargement is found in one of the iliac
fossa, being easily felt through the parietes of the abdomen — and'

COMPOUND, AND MIXED PREGNANCY.

139

when upon a vaginal examination, the uterus is found not to have
increased in size, nor undergone any change from a firm, unyield-
ing tissue, to one softened and elastic ; and very often this organ
will be found pressed by the abnormal tumor against 'some part of
the pelvic walls. Pain is generally present, especially when the
motions of the fetus can be felt, and which gradually becomes more
severe as its development proceeds. The pain is somewhat similar
to uterine pains, and at times it is constant, fixed, and circum-
scribed in the pelvis, groin, or umbilical region. Generally, during
the earlier period of abnormal gestation7it is very difficult to ascer-
tain its existence. While it exists, some of the symptoms of preg-
nancy, as cessation of menstruation, nausea, vomiting, mammary
enlargement, etc., may be present, but in many instances these have
been absent. There is a discordance of opinions among writers,
relative to the membrana decidna, some of whom assert that the
internal surface of the uterine cavity becomes covered with it dur-
ing extra uterine pregnancy, while others deny it; among the latter
may be named Dr. Eobert Lee, of London. But the statements of
M. Cazeaux, Prof. Meigs, Ramsbotham, and other investigators,
tend j.to prove conclusively, that the membrana decidua is formed
within the uterine cavity in abnormal pregnancies. Ramsbotham
remarks, "It^is a curious circumstance in the history of these
cases, that if the child should live until the term of gestation is
completed, as soon as that time has expired, the uterus takes on
itself expulsive action, which is attended with pain similar to the
throes of labor, and during these pains the deciduous membrane
is expelled from the cavity, with a slight sanguineous discharge;
the same also occurs on the death of the ovum, provided that be
premature." In these pregnancies we will frequently discover an
increase of the uterine volume, with ramollissement, especially dur-
ing the early stages, and will sometimes find a thick, ropy, gela-
tinous substance or mucus in the uterine neck.

The duration of abnormal pregnancy is very variable; most com-
monly it terminates in a few weeks or months; seldom exceeding
five months; and occasionally it has continued through a series of
years, even as long as forty-six years. It is stated, that in those
cases, where it has continued during the full period of labor, there
have been at the termination of the ninth month, symptoms simu-
lating labor, as intermittent pains more or less severe in character,
a commencement of dilatation of the os uteri, a discharge of muco-
sanguineous fluid, and true uterine contractions; and where this

140

AMERICAN ECLECTIC OBSTETRICS.

condition has continued for several years, these phenomena have
recurred at fixed or irregular periods — but they are by no means
constant.

The most common termination of extra-uterine pregnancy, is. by
a rupture of the cyst which incloses the fetus, and which may
be effected by a blow, violent exertion, or some similar cause, or it
may ensue slowly and gradually. This rupture is accompanied with
several symptoms of a grave nature ; at first, there will be severe
pain for several hours, and finally an agonizing pain will be fol-
lowed by tranquillity and a perfect quiet from suffering, with a sub-
sidence or flattening of the abdominal enlargement, or, perhaps, its
entire disappearance; the abdominal cavity experiences an increased
heat, and the patient, if the development was of some months'
date, will feel as if a voluminous body had been displaced; the skin
grows pale, faintings come on, the pulse becomes small and con-
tracted, a cold sweat covers the whole body, and frequently death
follows, owing to the hemorrhage produced by the rupture of the
cyst. Or, if hemorrhage to a copious extent should not ensue, or
it should be arrested, violent peritoneal inflammation will be the
result. Tne fetus in all these cases is usually dead, which may have
been the result of defective nutrition or some cause unknown ; and if
a new cyst is formed, which is sometimes the case, although very
dangerous to the mother, it is more favorable, because it may
probably form an abscess from which the fetus may be discharged,
and thus save the patient's life, or, it may permanently hold the
fetus while this undergoes several alterations, as hardening, or pass-
ing into the state of adipocire, all the fluid parts being absorbed, and
the cyst becoming gradually a solid, non-malignant tumor. Again,
it may terminate in a sac containing pus, in which the fetus putre-
fies, and is eventually discharged into the peritoneal cavity, the
intestine, or bladder, and which may give rise to violent peritonitis;
or, it may become coated with a bony, earthy, or semi-coriaceous
crust, and remain comparatively harmless, producing no distress,
except that occasioned by its weight and bulk.

Extra-uterine pregnancies have been divided into several varieties,
each variety being determined by the point of fixation of the ovule,
thus :

1. Ovarian Pregnancy, is that in which the ovum remains adherent
to the surface of the ovary, and is of two kinds — where the ovule is
found within the vesicle which held it previous to conception, and
where it is partly developed in the abdomen, and partly in the sub-

COMPOUND, AND MIXED PREGNANCY.

141

stance of the ovary itself. It may continue for five or six months,
when, from the augmented size of the fetus, the cyst ruptures during a
paroxysm of pain, and, as found after death, the fetus, with a large
amount of blood is expelled into the abdominal cavity. During
the presence of this abnormal pregnancy, most excruciating pain
about the pelvis, is experienced by the patient from time to time,
with constipation and dysuria ; and an examination of the uterus
per vaginam, detects it unaltered in size, form and consistence. The
pain is not constant, but regularly or irregularly intermittent, with
intervals of ease. But after the rupture of the cyst, the pain becomes
more severe, with syncope and finally death from peritoneal inflam-
mation. The existence of this form of extra-uterine pregnancy, is
denied b\' some authors.

2. Tubar, or Tubal Pregnancy, is probably the most frequent
variety of extra-uterine pregnancy. An arrest of the ovule takes
place in some portion of the Fallopian tube, between its fimbriated
extremity and its uterine orifice, and at which point the placenta
becomes attached to the inner face of the tubal canal, the walls of the
tubes forming the fetal sac. The growth and development of the
fetus proceeds for two, three, or four months, when the sac ruptures.
In this form of abnormal pregnancy, there is an early enlargement
over the symphysis pubis, and a vaginal examination will find the
uterus unchanged in size, etc., and movable, but unconnected with the
mobility of the tumor. As the fetus continues to grow, the female
suffers severe pain in the pelvis, which is increased after the rupture
of the sac, and is followed by excessive prostration and death. The
fetus is most commonly discharged into the abdominal cavity.

3. In Ventral, or Abdominal Pregnancy, the impregnated ovule fails
to reach the tube and falls into the abdomen, upon some portion of
the walls of which the placenta attaches itself. The pain, experi-
enced by the female in this variety of pregnancy, is situated in the
abdomen ; the enlargement is found in the iliac fossa, at an early
period; upon an examination per vaginam, the uterus, as in the pre-
vious species, is found unaltered, and more movable than in any
3ther of the abnormal pregnancies ; and the fetal movements may
sometimes be observed till the ninth month. The sac, which incloses
;he fetus, gradually forms adhesions with the surrounding parts, and
.nflammation most generally occurs, at some period, followed by
abscess, which discharges the fetus through the walls of the abdomen,
che rectum, or the bladder. Cases are reported in which the fetus has
remained within the abdomen for forty and fifty years, and others in

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AMERICAN ECLECTIC OBSTETRICS.

which normal pregnancy occurred during the presence of the first
fetus in the cavity of the abdomen.

There are several other varieties named by authors, to which a
brief reference may be made, as, Sub-peritoneo-pelvic pregnancy, in
which the ovum is situated between the two laminae of the broad
ligament, where it becomes developed, and which is, probably, the
least dangerous of any, as its situation favors the spontaneous expul-
sion of the fetal debris, and renders them more accessible,* should their
extraction become necessary ; Tubo-ovarian pregnancy, in which the
cyst surrounding the fetus is partly formed by the ovary, and partly
by the opening of the dilated tube, whose extremities have con-
tracted some adhesions with the ovarian tunic ; Tubo- abdominal preg-
nancy, in which the cyst is partly made up by the walls of the tube,
the placenta being attached to their interior face, while the other por-
tion of the surface of the ovule is in the cavity of the abdomen, and in
which cavity the fetus is usually developed ; Interstitial, or parietal
pregnancy, in which the ovule penetrates into the midst of the uterine
fibers, the cyst being formed by these muscular fibers alone — how
this is accomplished, is at present an enigma; Utero-tubal pregnancy,
where the ovum is retained partly within the tubes, and partly within
the uterine cavity; and Utero-tubo- abdominal pregnancy, in which the
fetus is in the abdominal cavity, the umbilical cord passing through
the canal of the tube and into the uterus, to the inner face of which
organ the placenta is attached.

In all these abnormal pregnancies, the ovule retains its proper
membranes, as the chorion and amnion, by means of the first of which
circulation is effected between the mother and embyro, and in those
cases where inflammation has been produced by the presence of the
ovum in the peritoneal cavity, a membranous cyst is formed some-
what similar to the caducous membrane of the uterus.

TREATMENT. — It is very difficult to determine extra-uterine
pregnancy, in its early stage ; our attention is seldom called to it
until at an advanced period, and often only at the time when rupture
of the cyst is about to ensue. And even could we ascertain it with
certainty at an early period, it is very doubtful whether any positive
means could be pursued to destroy the ovum, or check its further
development. Perhaps hydragogues might answer the purpose, but
this is merely a suggestive measure and one that requires trial and
observation before it can be recommended with confidence. All that
can be done in these cases, is to subdue pain, inflammation, and other

DISEASES OF THE PREGNANT FEMALE.

143

symptoms, upon general principles, keeping the bowels, which are
always constipated, in a soluble condition by laxatives or cathar-
tics ; indeed, when the strength of a patient will admit, I see no
objection to a free use of cathartic medication at an early period of
treatment. Attention must likewise be bestowed upon the bladder,
having it evacuated naturally, or by catheterism, at least twice a day.
When the strength of the patient fails, it must be supported by
tonics, wines, cordials, and nutritious diet, especially when an abscess
forms, with decomposition of the embryo ; and the abscess should be
opened as soon as the suppurative stage is present. At this time
active catharsis must be avoided. As the bones present, they must
be removed similar to other foreign bodies in the abdomen. Gas-
trotomy has occasionally been successful, in cases where the fetus had
died previously, but from a review of statistics relative to this point,
I believe the chances in favor of the mother's life are greater when
the case is left to nature, and the accompanying symptoms treated
upon general principles. Of course, in these cases, he must be a rash
practitioner who would seek to save the life of the child, as such
attempts have almost always proved fatal to the mother. If any por-
tion of the fetus should be discharged into the bladder, the operation
for stone may be performed; but we should always be certain of
this fact before attempting the operation.

CHAPTER XVII.

DISEASES OF THE PREGNANT FEMALE.

Between the uterus, and every part of the body, a strong nervous
sympathy exists, owing to the intimate relation maintained between
the sympathetic and cerebro-spinal system of nerves; and this sym-
pathy is more especially marked during the condition of pregnancy,
when the ganglia and plexuses of nerves, together with the blood-
vessels and absorbents of the uterus enlarge, and become roused
from a state of apparent inertia to one of energetic activity. This
change in the female system, gives rise to many symptoms, which
may be considered as indications of the healthy act of conception,
and which, as a general rule, should not be meddled with ; but,
when they become unusually severe or protracted, they are then
termed the " diseases of pregnancy," and require proper treatment

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AMERICAN ECLECTIC OBSTETRICS.

for their palliation or removal. As pregnant females are liable to
the same diseases as the unimpregnated, it would require a volume
to treat separately upon them ; I shall, therefore, confine this part
of the subject to those conditions more common during pregnancy.

"When the female is supposed, from the presence of the ordinary
symptoms, to have become pregnant, certain measures are necessary
for her to pursue, as well for her own benefit as for that of her off-
spring. All compression upon the abdomen or around the waist,
such as stays, corsets, belts, etc., should be at once removed, and
should not be resorted to until after parturition, if resorted to at all;
an attention to this point may prevent abortion, varices, uterine or
other diseases, on the part of the mother, which difficulties are very
apt to be the result of pressure and consequent obstruction of the
portal circulation, as well as of the great arterial trunks and veins
of the abdomen ; and on the part of the fetus, hydrocephalus,
deformity, or positions which may render the labor tedious and even
fatal. She should likewise be especially observant of her diet,
selecting that which is the most nutritious as well as most easily
digested, bearing in mind, that the gastro-uterine sympathy, as
well as the gradually increased volume of the uterus, tend greatly
to dimimish the energy of the digestive powers. Stimulants
especially, as alcoholic, vinous, or malt liquors, fats, much acidulous
food, and in instances where they prove decidedly hurtful, tea and
coffve, are to be avoided. The use of farinaceous vegetables, ripe
fruits, boiled or roasted meats, water, and milk, may be named as
among the best kinds of food and drink; and, though many
females may have indulged their appetites without any resulting
unpleasant symptoms, yet such a course is more apt to produce
various difficulties than is generally supposed, especially upon the
future of the fetus. Moderate exercise in the open air, especially
during the early months of pregnancy, should be very strongly
advised, with only occasional and not too prolonged bathing. Coi-
tion, though commonly indulged in during pregnancy, is extremely
unwise and improper; and though often practiced with impunity?
yet it is very apt to be followed by metrorrhagia, abortion, or some
defect in the mental or physical organization of the offspring-
Females subject to leucorrhea, immoderate menstrual evacuations,
abortions, as well as those of a nervous or impressible temperament
should be particularly warned against cohabitation during preg-
nancy. The symptoms or diseases of pregnancy, which frequently
require medical treatment, are first, those which are the result of

DISEASES OF THE PREGNANT FEMALE.

145

deranged circulation and nervous sympathy; second, those orig-
inating from the compression of the enlarged uterus upon the
neighboring organs; third, diseased conditions of the uterus or its
contents; and fourth, accidental diseases.

Among those symptoms depending upon deranged circulation
and nervous sympathy, one of the most common, as well as the
earliest, is vomiting, or morning sickness, as it is usually termed.
With the major part of females it is the first sign Of pregnancy,
commencing usually about the fourth or sixth week, and sometimes
immediately after conception, and continuing for a few months, or
even up to the parturient period. The female experiences more or
less nausea from the time of rising in the morning, which may at
first be removed by eating the morning meal, but which soon
becomes followed by vomiting of a greater or less degree of severity
and duration ; occasionally, the vomiting becomes exceedingly vio-
lent, everything being rejected from the stomach, and if not
checked, the female may die from exhaustion or starvation ; or
premature labor may ensue, followed by hemorrhage of an alarming
character. Where the vomiting occurs during the first three or
four months of pregnancy it is dependent upon gastro-uterine sym-
pathy— is principally confined to the morning, lasts from ten
minutes to an hour or two, each day, and usually ceases in from
two to four months; the matter evacuated is thick, slimy, colorless,
greenish or blackish, frequently acid, and if the effort at vomiting
be severe, a little bile or even blood may be mixed with it. This
sympathetic vomiting seldom falls under the practitioner's care,
unless it becomes very severe; and indeed, no especial means are
required for its removal when not too violent or prolonged, as it is
merely a normal effect of conception.

When the vomiting occurs only in the morning, and is compara-
tively slight, it may be palliated by some aromatic infusion, and if
the discharges are very acid, magnesia, alkalies, with aromatics, or
charcoal, will be found efficient ; sometimes these agents will exert
but little effect upon the acidity, in which cases, they will have to
be laid aside and acids employed, as Lemon-juice and water, a solu-
tion of Tartaric or Citric acid, or acid wines. Should the discharges
contain much bile, mild cholagogue laxatives will be found bene-
ficial, as a combination of two parts of Rhubarb and one of
Bicarbonate of Potassa, administered three times a day, in doses
of eight or ten grains of the mixture, or sufficient to produce one
or two mild alvine evacuations, daily; or Leptandrin may be given

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alone, or with a very small proportion of Podophyllin, Apocynin
or Magnesia.; When the vomiting is accompanied with much pain
in the stomach, opiates, Cypripedin, Lupulin, Scutellarin, with coun-
ter-irritation to the epigastric region, may be employed with
advantage; and in severe and obstinate cases of pain, I have suc-
ceeded in giving relief, when other means had proved inutile, by
applying a warm fomentation over the epigastrium, composed of
Hops and Stramonium leaves.

When the vomiting is violent and obstinate, various means have
been advised, all of which have at times proved beneficial ; it must
be remembered, that while a certain course may produce a good
.nfluence on one patient, it may have no effect whatever, upon
another, hence the necessity of an acquaintance with these several
means. As severe vomiting is frequently accompanied with gastric
or hepatic derangement, it will be proper to resort occasionally to
cholagogue laxatives, as before named, after which an infusion of
Swamp Dogwood bark (Cornus Sericea), may be administered. I
have employed this infusion in a great number of cases, accom-
panied with the application of a sinapism over the last dorsal
vertebras, with much benefit ; the infusion may be drank freely
through the day. An infusion of the bark of Ptelea trifoliata, has
likewise been used advantageously in severe vomiting ; and in
several instances I have derived much benefit from a pill, composed
of one and a half grains, each, of Caulophyllin and hydro-alco-
holic extract of Cimicifuga ; one pill for a dose, to be repeated
three or four times a day. In cases where the circumstances of
the patient will allow, Champagne wine, according to Prof. Meigs,
taken during the meal (should vomiting occur after the meal), will
almost almost always prevent it. I have occasionally met with
severe cases of vomiting, in which, after the employment of the
usual remedies without efiect, Lobelia has produced the desired
influence ; in such cases, I have rubbed together one drop of Oil
of Lobelia and thirty grains of Sugar, and given one sixth of the
mixture for a dose, repeating it every ten or fifteen minutes until
relief ensued, which generally followed the first or second dose,
rarely requiring a third or fourth. Notwithstanding all these
remedies, it will happen, sometimes, that no relief will be experi-
enced, and the patient continues to suffer up to the fourth month
without any amelioration of her condition ; yet, even in such
cases, the physician should not add to her suffering by giving up
the case as beyond remedial action, but should cheer her up, and

DISEASES OF THE PREGNANT FEMALE.

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endeavor to fortify her spirits by the anticipation of better effects
from the next means to be used. Among the other means which
have been recommended for this distressing symptom, but which I
have not had occasion to use, are Ice, Iced waters, Effervescent
draughts, as Soda or Mineral water, Creosote, Turpentine, Seidlitz
powders, Lime-water, infusion of Wild Cherry-tree bark or Peach
leaf, and tincture of £Tux Vomica. In all these cases, the diet
should be of the lightest character, and if the stomach be found
to possess less irritability at any certain period of the day, this
period must be selected for taking the principal meal. The prac-
titioner must likewise ascertain whether fluid or solid food agrees
best with the stomach, and advise the patient accordingly. The
patient should not move about too much, and, sometimes, rest in
the horizontal position will be absolutely required. Gastritis,
indigestible food, constipation, certain odors, etc., may likewise
give rise to, or increase the severity of vomiting during utero-ges-
tation, all of which should be borne in mind during treatment,
that if present as existing causes, they may be removed.

Where vomiting occurs only during the early part of the day,
Prof. Meigs recommends a cup of coffee with toast to be taken by
the patient while in bed, after which she should, if possible, sleep
again for a short time ; upon subsequently arising no nausea or
vomiting will take place.

The vomiting that occurs after the fourth month of pregnancy
is owing to the pressure of the gravid uterus upon the stomach,
and is often very difficult to relieve ; indeed, palliation is all that
can be expected. Tonics, and antispasmodics may be employed in
these cases. I have frequently met with cases which resisted all
treatment, ceasing only at parturition ; and again, I have consider-
ably mitigated the severity of this distressing symptom, by keeping
the bowels in a regular condition, and administering small doses of
Sulphates of Quinia and Morphia, or of Sulphate of Morphia and
Caulophyllin, or Scutellarin, Sulphates of Quinia and Morphia,
with counter-irritation over the last dorsal vertebrae. In this form
of vomiting, all food, or whatever is received into the stomach is
rejected, and the patient suffers from inanition ; indeed, the princi-
pal subject of fear is, that she may die from actual starvation. It
should be our aim to discover what variety of food best agrees
with the stomach, and the period of the day in which this organ
is the least irritable, that advantage may be taken of that period
for taking a light meal. In some instances where vomiting fol-

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AMERICAN ECLECTIC OBSTETRICS.

lowed the reception of everything taken into the stomach even in
moderate quantity, I have succeeded in sustaining the powers of
the patient up to the period of parturition, by giving half-teaspoon-
ful, or teaspoonful doses of milk, cream, gruel, etc., every hour or
two throughout the day, occasionally with a few drops of Brandy,
or other stimulant added, accompanied with injections of Elm bark
infusion, Port wine, and Laudanum, repeated two or three times a
day, and occasionally changed for injections of gruel, starch- water,
etc. In these cases, the less medicine the patient swallows, the
better will it be for her, except when imperiously demanded.

Frequently the vomiting becomes so excessive as to threaten the
life of the patient, as before observed, from starvation ; for it is
seldom the case that abortion is produced by puerperal nausea,
though it frequently ensues from emetics. In such instances, after
a fair and patient, but fruitless trial of all remedies to overcome
the difficulty, and sustain the patient's strength, we may be com-
pelled to resort to premature delivery. This, however, is not to be
thought of, unless the patient's life is actually endaugered, and
should never be undertaken without having first consulted with
one or more medical men. Dubois, who in the course of thirteen
years met with twenty fatal cases, advises never to perform the
operation, even though the vomiting be violent, when the patient,
however feeble and emaciated she may be, is not obliged to retain
her bed, when a small portion of aliment can be retained, and when
intense and continuous febrile action has not been induced ; he
also prohibits the operation when signs of extreme exhaustion are
present, as loss of vision, cephalalgia, coma, somnolence, and men-
tal disorder. A timely interference is advised, at a period charac-
terized by an incessant vomiting, whereby all food, and sometimes
even a drop of water is rejected; where emaciation and debility
are present, requiring absolute rest; where the least movement or
mental emotion causes syncope; where the features become
decidedly changed; where there is severe and continuous febrile
action, with excessive and penetrating acidity of the breath, and a
failure of all other means.

When vomiting has been very distressing during labor, I have
frequently given prompt relief by the administration of the tinc-
ture of Gel8eminum, and would suggest its employment in these
obstinate vomitings during pregnancy.

Ptyalism, or salivation, frequently occurs during the early months

DISEASES OF THE PREGNANT FEMALE.

149

of gestation, and seldom requires any treatment. Rarely, however,
it becomes very severe, resembling mercurial ptyalism, but differing
from this in the absence of tenderness of the gums and disagreea-
ble fetor of the breath ; the fluid secreted is colorless and trans-
parent, or tenacious and frothy, with an unpleasant taste, commonly
accompanied with acidity, and often inducing vomiting. As a
general rule, this symptom needs no treatment, and indeed, treat-
ment effects but very little benefit ; the best plan is, to regulate the
action rf the bowels by mild aperients, and wash or gargle the
mouth and throat witn some astringent infusion, as of Golden
Seal, Geranium, aud Sumach bark. In cases of acidity, Lime-
water may be used with some advantage. The secretion, when
profuse, may be moderated, by constantly holding in the mouth
some candied Sugar, or a lump of Gum Arabic.

Anorexia, or a loant of appetite, and a dislike for ordinary aliments,
are symptoms frequently met with at various stages of utero-gesta-
tion. These may be owing to the sympathetic actions existing
between the uterus and digestive organs, to a torpid state of the
organs subservient to digestion, or to an unloaded condition of the
alimentary canal. Usually, puerperal anorexia requires but little
attention; but where treatment is required, it must be based upon
the supposed cause of it— thus, if it be suspected as a result of
nervous sympathy, antispasmodics will generally remove it; if it
originate from torpor of the digestive apparatus, mild aperients,
with tonics will be found useful ; and if it be induced by plethora,
or an accumulation of morbid matter in the alimentary canal, mild
purgatives will be essential. Indeed, I would remark here, that
throughout the whole period of utero-gestation,if the bowels be kept
in a soluble condition by mild aperients, or by the use of proper
food, many of the distressing symptoms common to this period will
be avoided. Flatulence maybe removed by an infusion of Fennel
seed, or other aromatic, or by compound spirits of Lavender given
in some sweetened water. To overcome these difficulties, some
authors recommend emetics, but I am decidedly opposed to their
use:, firstly, because milder measures will accomplish all that can
be desired; and secondly, because emetics have a tendency to pro-
duce abortion, and which may be avoided by other efficient and
less hazardous means. There are some practitioners who proceed,
apparently, as if they supposed every patient's stomach to be a
strong metallic vessel, capable of being acted on by emetics, power-

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ful stimulants, drastic purgatives, etc., etc., without the least injury
whatever, but always with benefit; such physicians, of all men, are
the least adapted to obstetric practice, and I might add truly, or
any other.

Either with or without anorexia, the patient may have "long-
ings," or a desire for certain articles, which are sometimes unnatu-
ral and even disgusting. When these longings are not directed to
unwholesome or dangerous articles, there is no reason why they
should not be indulged ; neither is there any necessity for interfering
with any particular dislikes which may have been produced in the
patient's mind. In relation to these longings, and their influence
upon the fetus in utero, when ungratified, as well as to the effects of
the maternal mind, generally, upon it, there is much discordance of
opinion among medical men, some believing that the embryo is
acted upon by strong mental emotions of the mother, while others
deride the idea. I must eonfess, that too much evidence, of a
direct and satisfactory character, has been at various times pre-
sented to me, to permit me for a moment to doubt this point ; and
I am thoroughly convinced, that the fetus in utero is subject to
influences and changes, resulting entirely from the mind of its
mother, when under strong or continuous action. How, or why
this is produced, is as difficult for me to explain, as it would be to
account for the cessation of a severe labor-pain on the entrance of
the accoucheur into the puerperal room, or the sudden dissipation
of toothache upon obtaining a sight of the forceps, or to explain
why one man should be actively purged upon seeing another swal-
low a nauseous dose of medicine. I know, "sympathy," and
"imagination" are held up as replies — but if these are applicable
to the latter cases, why not to the former ? A greater attention to
the efforts of nature, as witnessed in the human system, and less
attention to speculative hypothesis and dogmatic authority, would
tend much to advance the true science of medicine. He who really
desires a knowledge of the truth, will not hesitate to receive it
from any source.

Diarrhea may occur and usually yields to the ordinary treatment
for this disease, when independent of pregnancy. It may be
owing to intestinal irritation, which may be the result of constipa-
tion preceding pregnancy, or it may be induced by the sympathy
existing between the intestines and the excited uterus; under either
of these circumstances, it would be proper to give our officinal

DISEASES OF THE PREGNANT FEMALE.

151

compound Syrup of Rhubarb and Potassa, and to continue its
use until it has thoroughly evacuated the bowels, after which,
antispasmodic and mild astringent infusions should be adminis-
tered. In some instances, Leptandrin, and Podophyllin will prove
more efficacious than the above syrup. When the diarrhea
depends upon chronic inflammation of the mucous membrane of
the intestines, it becomes of a serious character, and unless treated
promptly and properly, may terminate fatally. In this case,
mucilaginous draughts, as infusion of Peach leaf and Marshmal-
low, or of Elm, and Wild Cherry, should be freely given — warm
fomentations should be applied over the abdomen, and mustard
to the dorsal and lumbar portions of the vertebral column; an
enema, composed of Elm infusion one fluidounce, tincture of
Prickly- Ash berries two fluidrachms, and Laudanum twenty or
thirty drops, should be given immediately after each alvine dis-
charge, or oftener should the symptoms require it. In addition
to these, the ordinary treatment for inflammation of a similar
character, must be pursued, meeting the symptoms as they present
themselves. In some cases, I have derived benefit from the offi-
cinal compound tincture of Virginia Snakeroot, administered in
enema, half a fluidrachm to half a fluidounce of starch -water,
every hour or two. The diet should be light and small in quantity,
consisting principally of boiled Milk, boiled Rice, Arrowroot, etc.
Diarrhea more often occasions abortion than does constipation, in
consequence of tenesmus, and which usually occurs about the third
month. As with all other affections during pregnancy, care must
be taken to avoid active or powerful catharsis whatever may be
the agents employed in their treatment.

Heartburn or eardialgia, is a distressing symptom, and may be
present during the early period of conception, not until the third
or fourth month, or may be entirely absent. It may be occasioned
by sympathetic action, by the use of certain articles of diet, and
by the presence of bile in the stomach, but most generally, it
arises from acidity of the stomach ; it is also said to be caused by
emotions of the mind, and an affection of the eighth pair of nerves.
There is heat or a burning sensation in the epigastric region,
which extends upward along the esophagus, with pyrosis or
eructations of a clear, bilious, sour, and bitter fluid, and is fre-
quently accompanied with a peculiar sensation of dragging from
the stomach toward the spine ; eating aggravates the difficulty.

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AMERICAN ECLECTIC OBSTETRICS.

There is usually no febrile or other constitutional disturbance
present; the appetite is commonly impaired. This symptom may
usually be mitigated by an attention to the bowels, removing
acidity by alkalies in aromatic infusion, by a rigid attention to
diet, which should be light, nourishing, and easy of digestion,
and by the use of moderate exercise in the open air. In very
painful and obstinate cases, counter-irritation, as sinapisms, etc.,
applied to the epigastrium will be productive of benefit. A long-
continued use of alkalies will injure the tone of the stomach.
Sometimes, alkalies will fail to produce the slightest relief; in such
cases, a resort to acids will often effect the desired result ; solution
of Citric Acid, Tartaric Acid, or Lemon-juice may be used, or
Elixir of Vitriol. As soon as some relief has been afforded, an
attempt may be made to invigorate the powers of the stomach,
for which purpose I have met with much benefit from a pill com-
posed of Sulphate of Quinia, ten grains, alcoholic extract of iuix
Vomica, one grain, Ptelein, a sufficient quantity to form a pill-
mass ; mix together, and divide into twenty pills, of which one
may be given for a dose, and which should be repeated three times
a day. Generally, females obtain a temporary relief from this
symptom, when not obstinately severe, by taking Lime-water, or
chewing Magnesia, Chalk, or Peach-kernels.

Gastrodynia, spasm or cramp of the stomach, is frequently the
result of some error in diet, but may also be occasioned by cold,
or violent mental emotions. Its attacks are often sudden, more
transient than heartburn, but far more severe. Violent pains of a
neuralgic character dart from the sternum through to the back or
shoulders, being accompanied with great distension, flatulence,
restlessness, and anxiety ; it may be so severe as to occasion prema-
ture labor, or the death of the fetus. The treatment should be
prompt and energetic, warm fomentations, or sinapisms should be
applied to the epigastrium, the bowels should be opened by a mild
laxative clyster, and an opiate administered, as the officinal com-
pound powder of Ipecacuanha and Opium. In some instances of
a severe and obstinate character, I have succeeded in giving relief
with the officinal compound tincture of Lobelia and Capsicum,
also with the tincture of Gelseminum. "When the attacks are
frequent, they may be overcome by keeping the bowels regular,
neutralizing acidity of the stomach, and administering a solution
of Sulphate of Quinia, in tincture of Gelseminum. The diet

DISEASES OF THE PREGNANT FEMALE.

153

should be light, and nutritious, avoiding fats, acids, and stimulants.
Alkalies, aromatics, and anti-spasmodics, are the only internal
remedial agents generally required.

Constipation is a common attendant of pregnancy, and is fre-
quently very obstinate and troublesome. It is caused by the
compression of the gradually-developed uterus upon the rectum,
which diminishes its diameter, as well as impairs its activity ; con-
stipation may also be owing to digestive derangements, improper
food, sedentary living, and other causes calculated to lessen the
energy of the intestines. Various symptoms depend upon this
condition of the bowels, as headache, or a sense of fullness and
weight in the head, sleeplessness, irritability, pains in the abdomen,
bloody mucous discharges, nausea, and, in the latter period of
pregnancy, false pains. Sometimes, notwithstanding accumulation
of fecal matter in the intestines, there will be small discharges of
a liquid character. Constipation is a symptom always to be
dreaded in the pregnant female, because of its liability to produce
abortion from the large amount of feces collected in the rectum,
requiring great expulsive effort to remove, as well as its tendency,
at the time of parturition, to cause protracted labor, peritonitis, or
convulsions. Piles are usually a consequence of constipation in
the pregnant female. In the treatment of costiveness during
pregnancy, I prefer the use of warm laxative enemas to active pur-
gatives administered by the mouth, and for this purpose an infusion
of Boneset with the addition of Molasses and Castor Oil, may be
used daily, and after the rectal accumulation has been removed, a
daily enema of warm water may be substituted for the previous
one. If medicine is required, I prefer small laxative doses of
Rhubarb and Bicarbonate of Potassa or Soda, to any other agent
with which I am acquainted. Active cathartics are seldom
required, and should always be used with great care during
pregnancy, on account of their tendency to produce premature
labor; the secret of success consists entirely in maintaining one
daily alvine evacuation. I prefer scooping out the contents of the
rectum in these cases, to the use of cathartics, to be followed by
enema of warm water, and powders of Rhubarb and alkaline
Bicarbonate, daily. In diarrhea, the practitioner should always
ascertain if it was preceded by constipation, and should this be the
case, laxative measures must be the first adopted. No female
should be allowed by a physician to enter the parturient state with
11

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AMERICAN ECLECTIC OBSTETRICS.

constipated bowels ; and in those instances where the practitioner
attends the patient previous to full term, he is highly reprehensible
if he neglects the proper attention to this condition. The diet in
these cases may be such as to assist very much bringing about the
desired regularity, without the aid of physic, as brown bread,
mush and molasses, hasty pudding and molasses, fig3, stewed
prunes, dates, ripe fruits, and dried laxative fruits stewed, as
apples, peaches, plums, etc. Any irritability of the bowels which
may follow a removal of constipation can be allayed by some gentle
sedative, as extract of Hyoscyamus.

Headache, or cephalalgia, is of very common occurrence during
pregnancy, and attacks all temperaments. The pain may be con-
stant or periodical, acute or dull, and may be located in one partic-
ular part of the head, or over the whole of it. Sometimes, especially
when acute, it is also of a throbbing character, and not unfrequently
there is an intolerance of light and sound. Usually it is owing to
some deranged condition of the digestive organs, and may be readily
removed by a mild laxative or two, and subsequent attention to
diet. It may, likewise, originate from mental emotions, fatigue,
stimulants, and coitus. The headache which occurs during the
early months of utero-gestation is of a nervous character, and is not
regarded as a dangerous symptom ; while that which occurs during
the latter months, is owing to plethora, is usually attended by evi-
dent signs of cerebral congestion, and must be treated promptly and
energetically, that serious results may not ensue. This latter form,
unlike the former, instead of being relieved by the recumbent
position is more or less aggravated by it, and is frequently accom-
panied with a quick, full, and strong pulse, flushed countenance,
suffused or heavy eyes, heaviness of the lids, and photophobia; the
carotids pulsate with unusual force, and a sensation of giddiness is
present, which is increased on stooping. If this form of headache
is permitted to continue without relief it will almost assuredly ter-
minate in convulsions.

The nervous form of headache may be removed, as before observed,
by regulating the bowels, and attending to the diet; and, probably,
antispasmodics may be required, as some preparation of Valerian,
Black Cohosh, Scullcap, Ladies-Slipper, Camphor, or even Stra-
monium, Hyoscyamus, etc.; and in some severe instances, counter-
irritation to the sub-occipital region, or behind the ear. I have
derived considerable advantage from a pill composed of Sulphate of

DISEASES OF THE PREGNANT FEMALE.

155

Quinia half a grain, hydro-alcoholic extract of Black Cohosh one
grain and a half, and extract of Belladonna one eighth of a grain ;
of which, two or three are to be given daily.

The plethoric variety requires somewhat different treatment ; the
bowels must be kept entirely free from any disposition to constipa-
tion, counter-irritation must be intermittingly applied to the whole
length of the spinal column, and active diuretics may be safely
and freely given. In very severe cases cupping may be applied to
the temples, or nape of the neck. Moderate diaphoresis will like-
wise be found serviceable, and should be effected by the use of the
simple diaphoretic herbs in infusion, without the administration
of any preparation of opium. Although local depletion may act as
a beneficial palliatory measure, yet general oieeding, which is so
frequently resorted to and recommended by certain physicians and
authors, must be specially guarded against, as it debilitates the
female, rendering her liable to premature delivery, tedious labor,
perhaps requiring instrumental aid or hemorrhage after parturition,
and frequently tends to the destruction of the fetus. When the
severe symptoms have been renewed, the officinal compound syrup
of Partridgeberry, or the Parturient Balm, may be employed and
continued daily up to the full term.

Convulsions often attend the condition of pregnancy ; their most
usual periods of attack are in the latter months, during parturition,
or shortly after delivery. Those convulsions attended with or
preceded by signs of general plethora, and cerebro-spinal conges-
tion, and commonly termed "puerperal convulsions," will be treated
of in another part of the work. At the present time, I would call
attention to a form of convulsions, which I have met with as early
as at the second month of gestation, and which occurs much more
frequently than the true puerperal convulsions. They most gene-
rally occur in anaemic or hysterical patients, or in those whose ner-
vous systems have been exhausted b}7 any depressing cause, and
though when the attacks are light no bad results follow, yet they fre-
quently occasion premature labor, or by appearing at the parturient
period, perplex, embarrass and, perhaps, alarm the practitioner.
They are, undoubtedly, of an hysterical character, and differ from
the true puerperal convulsions, in being often preceded or attended
by the globus hystericus and borborygmus, with a small, hard pulse
peculiar to ordinary hysterical attacks ; the motions of the limbs
are likewise more violent, the eyes roll or stare with a wild expres
sion, and though they may be unnaturally brilliant, yet there will

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AMERICAN ECLECTIC OBSTETRICS.

be no suffusion, and the pupil is not insensible. Occasionally the
ordinary concomitants of sobbing, crying, or screaming will take
place. Urine, of a pale color, is frequently voided in large quanti-
ties. In the treatment of this form of convulsion I place the greatest
reliance on the officinal compound tincture of Lobelia and Capsicum,
(Antispasmodic tincture,) which may be administered in doses of from
a fluidrachm to half a fluidounce, and should be repeated every ten
or twenty minutes, according to the indications, until the attack
has been overcome. Usually the first dose, if sufficiently large, will
suffice ; sometimes a second will be required, and rarely a third.
In the meantime, during the absence of these convulsions, the
patient must be placed upon a generous diet of an easily digestible
character, the bowels must be kept regular, wine or ale may be
allowed, with some chalybeate preparation, the use of which
should be continued during the whole course of utero-gestation,
unless otherwise contra-indicated ; all exciting influences should be
removed as much as possible, quiet should be enjoined, excessive
depletion by diaphoresis, diuresis, or catharsis are to be avoided, and
coitus must be absolutely prohibited. In these instances, I commonly
leave the antispasmodic tincture with the patient, to be admin-
istered by her friends whenever an attack occurs, and which effects
its influence without the necessity of my presence on every occasion.
"With this class of patients, the practitioner should always be very
careful to have a* vial of the above tincture on hand at the period of
parturition, for it not uncommonly happens that one or several
attacks come on during the labor, as well as subsequently, and
which may be immediately overcome by its prompt administration,
as has invariably been the case in my own practice.

According to Andral and Gavarret, the fibrin of the blood is
diminished during the first six months of pregnancy, but subse-
quently becomes augmented, even to a considerable amount above
the usual physiological portion, assuming the characteristics of
inflammatory blood, and manifesting the buffy coat after venesection.
In addition to which, the quantity of the blood is also considerably
increased beyond the usual normal proportion. These changes in
the blood are, very probably, due to an increased nutrition, by which
chyle is formed in greater abundance from the food, and conveyed
to the bloodvessels. This plethoric condition is a natural and salu-
tary consequence of pregnancy, and under ordinary circumstances
requires but little attention, further than active exercise and mode-

DISEASES OP THE PREGNANT FEMALE.

157

rate diet. But occasionally these additions to the quantity and
quality of the blood become so great as to develop symptoms
demanding prompt therapeutic treatment, which is more especially
the case with indolent females, those who live luxuriously, and those
of sanguine habit; it may also be induced by constipation. These
symptoms are headache, somnolence, flushed face, vertigo, dyspnoea,
full and frequent pulse, heat of the skin, depressed spirits, and high-
colored urine. Sometimes the general plethora gives rise to local
plethora, which may be followed by congestion of a serious character
in the brain, lungs, or uterus. This latter organ, during pregnancy,
is the most liable to hyperemia, which may be known by a sensation
of fullness and weight iu the pelvis, groins, and thighs, tension or
swelling of the abdomen, pain in the kidneys or loins and even symp-
toms of premature labor ; and, not unfrequently, this condition of
the mother exerts an influence on the fetus, in consequence of which,
its movements become less frequent and weaker, or perhaps cease
altogether, but which, if not allowed to proceed too far before giving
relief, will again appear with the removal of the local plethora.

Whenever the symptoms of general or local plethora become so
severe as to require remedial measures, and no symptoms of approach-
ing miscarriage have been manifested, it will frequently be advisa-
ble to commence the treatment with a cathartic, followed by diuret-
ics, which will be found to exert a safer and more salutary depletory
influence, than even general bleedings, which are so highly recom-
mended by many medical writers. Counter-irritation by dry cup-
ping, sinapisms, or other means should be applied to the upper por-
tion of the spine ; the legs and arms may be rubbed or bathed with
some stimulating liquid, and, very frequently the wet sheet, or rather
bandage, applied around the abdomen and pelvic region will effect
much benefit; if the case be very severe, tending to a miscarriage,
cupping may be pursued, applying the cups to the loins and over
the sacrum. On no account must large or small general bleedings
be had, for though they may occasionally be followed by present
relief, yet their after consequences are much to be dreaded; beside
it is a well-established fact at this day, that bleeding rather increases
than diminishes the tendency to an inflammatory condition of the
blood. After the symptoms have been removed by the above treat-
ment, the subsequent measures should be light diet, moderate exer-
cise, regularity of the bowels, and the use of the Parturient Balm,
which will be found a most excellent agent at this time, with an
occasional use of diuretics, and the wet sheet or bandage. Hemor-

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AMERICAN ECLECTIC OBSTETRICS.

rhage, or symptoms of miscarriage, are to be treated as laid down
elsewhere for these difficulties.

I should observe here, that local congestion of the uterus, or of
any other organ is not necessarily connected with general plethora,
but may exist with a state of general antenna ; under which cir-
cumstances, the nervous and vascular systems will be found in an
extremely excitable condition. In such cases, after the removal of
the local hyperemia, proper attention should be bestowed upon
the existing anaemia.

Odontalgia, or toothache, is frequently a troublesome symptom
with pregnant women; it may occur with or without caries, and
may appear at any period of utero-gestation, often continuing until
parturition ; the pain is most usually intermittent, but is occasionally
continuous. Generally, it is owing to increased irritability of the
nervous system, and at times to a sanguineous congestion of the
jaw. As the extraction of a tooth during pregnancy is frequently
followed by premature labor, it is not prudent to resort to this
expedient, even should caries be present; and it seldom happens
that any alleviation of the suffering follows the operation. How-
ever, should the pain be owing to a carious tooth, the patient suffer-
ing severely without any relief being afforded, and other means
have failed, then the tooth may be extracted by a skillful dentist,
and probably the administration of chloroform would entirely pre-
vent any bad influence upon the generative sj^stem from the shock
of the operation. The proper treatment in these cases is the
administration of antispasmodics with tonics, as combinations of
Scutellarin, Cypripedin, hydro-alcoholic extract of Cimicifuga, with
Sulphate of Quinia, or, tincture of Gelseminum with Quinia; the
bowels should be kept in a regular condition by gentle laxatives '■>
and as a local application, washing the mouth frequently with cold
or tepid water and salt will be found useful. In very severe and
obstinate cases, counter-irritation behind the ears will be followed
by excellent results, as a sinapism, stimulating liniments, and even
the irritating plaster. Tincture of Aconite root, employed in friction
beneath the ear, is said to be a very effectual remedy, and is cer-
tainly deserving a trial in this distressing complaint. If caries be
present, the cavity should be cleansed, and the following mixture
applied on cotton or lint, and frequently repeated until relief is
obtained, viz.: Take of Oils of Cajeput, Cloves and Amber, each
one fluidrachm, Camphor one drachm, rub the Camphor with the

DISEASES OF THE PREGNANT FEMALE.

159

oils until it is dissolved. Or, the officinal compound tincture of
Camphor, may be applied similarly. In the toothache of preg-
nay, ncthe breath is very apt to be acid, and will redden litmus ; fre-
quently, when constipation is a co ncomitant, its remoual will be
followed by a cessation of the pain.

It is frequently the case that the nervous excitement produced
in the uterus by the condition of pregnancy extends to the kidneys
and ureters, giving rise to spasmodic action of the ureters, attended
with severe pain along their course, and often strangury, and which,
if not promptly relieved, may induce premature labor. In these
instances counter-irritation should be applied over the lumbar
region, and sedatives administered internally. The tincture of
Gelseminum alone, or combined with the tincture of Cimicifuga,
will prove a very useful remedy. Where strangury is present, an
infusion of Marshmallow root, with tincture of Camphor will be
found beneficial, together with an application of pounded Onions
over the pubic region.

The bladder may likewise become the seat of sympathetic
nervous excitement, especially the urethra and neck, giving rise to
a constant sensation or desire of urinating, and the urine passes in
small quantities, frequently with pain and difficulty, and is likewise,
with some patients, attended with excessive irritability of the
external generative organs, and more or less severe and distressing
itching, which is increased at night. The internal use of mucila-
ginous diuretics will occasion much relief; infusion of Marsh-
mallow root and Trailing Arbutus, or Marshmallow and Peach leaf,
with ten or twenty drops of the spirit of Nitric Ether may be
given, and repeated several times a day; sometimes, liquor Potassa
may be advantageously combined with the diuretic infusion. The
bowels should be kept regular, and the diet should be of a mild,
not stimulating character. For the itching of the genitals, cold
applications should be employed, and the parts kept well cleansed.

Occasionally, from pressure, or perhaps from an increased deter-
mination of blood to the uterus, which withdraws this fluid fron
the immediate neighboring parts, there will be found a torpor of
the bladder, giving rise to a retention of urine and its difficult
passage. This is a more serious difficulty than the previous one,
on account of its tendency to produce retroversion of the uterus.
It must be met with diuretics, as infusions of Queen of the Meadow

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AMERICAN ECLECTIC OBSTETRICS.

root, Wild Carrot, Trailing Arbutus, Dwarf Elder, etc. ; the
patient should be advised to empty the bladder often, if possible,
by her own efforts, and should these means fail, the urine must be
removed by the careful introduction of a catheter : which operation
must not be delayed for too long a period.

Syncope, or fits of fainting, frequently attend the pregnant condi-
tion, aud may occur at any period from conception to parturition,
though more commonly during the earlier months ; vertigo, or dim-
ness of sight, is also apt to be present, with sometimes tinnitus, and
weakness of the knees. These affections may be owing to debility
from whatever cause, to extreme nervous susceptibility, or to
plethora. Syncope generally occurs while the patient is standing,
is seldom of long duration, and very seldom causes any serious
results. However, when frequently repeated it may induce prema-
ture labor, which should be carefully guarded against. The treat-
ment should be that usually pursued in syncope at other times ; put
the patient in a recumbent position, in a place where there is a cir-
culation of cool air — dash cold water on the face — apply Ammonia,
Ether, or Vinegar, etc., to the nose, and after her recovery, should
there be much debility, with coolness of the surface, diffusible
stimuli may be administered internally, with frictions to the limbs,
and, in severe cases, along the spinal column. "When the attacks
are severe, and occur frequently, the officinal compound syrup of
Partridgeberry, may be given two or three times a day, with benefit ;
and if the patient be weak, tonics may also be employed.

Palpitation of the heart is not an unusual occurrence, during preg-
nancy; it is a distressing symptom, and though by no means dan-
gerous, it occasions much alarm to the patient. It may happen at
any period of utero-gestation, and may be owing to mental excite-
ment, derangement of the digestive organs, pressure, flatulency, or
sympathetic nervous irritation. During its presence, it may be
relieved by the administration of an alkali, if acidity and flatulency
are present; by a mild laxative if the bowels are confined; and
under other circumstances, Ether, Chloroform, compound spirits of
Valerian, Musk, or other antispasmodics may be employed, accord-
ing to indications. Ten or twenty drops of the tincture of Digi-
talis, given daily, will frequently overcome the difficulty. During
the interval, the compound syrup of Partridgeberry will be found
beneficial in preventing a return of the palpitation, and should the

DISEASES OF THE PREGNANT FEMALE.

161

patient be of an anaemic habit, the proper chalybeates must be used
in conjunction. The diet must be mild and stimulating, the patient
should exercise moderately, her dress should be loose, coitus should
be abstained from entirely, and the mind should be kept perfectly
tranquil.

Dyspnoea, or difficulty of breathing, may occur, in the early months,
from sympathy, and at a later period from plethora, or from pres-
sure of the enlarged uterus ; it may likewise be owing to derange-
ment of the digestive organs, thoracic disease, cardiac disease,
tumors, etc. The treatment will consist in the administration of
antispamodics, as Lobelia, Ether, etc., attention to the regularity of
the bowels, and a course similar to that just named for palpitation.
When owing to organic diseases, or congestion of the lungs, these
must be attended to according to their indications. When the diffi-
culty is owing to the enlargement of the uterus, but little relief can
be expected until the delivery of the fetus, hence, there is no neces-
sity for injuring the patient's system by the employment of medi-
cines.

Cough sometimes occurs, independent of cold or existing disease,
and which, in the earlier months, is owing to sympathetic action ;
in the latter, to pressure. The cough is usually short, dry, hack-
ing and constant; occasionally very severe, with but little or no
expectoration, no febrile symptoms, and no change in the pulse,
and is apt to cause premature delivery. It may be treated by nar-
cotics, antispasmodics, rest, and regularity of the bowels, with a
proper attention to diet. In one case far advanced in pregnancy,
where the cough was very severe and incessant, and had resisted all
previous means for several weeks, I succeeded in affording relief
by applying a stimulating plaster between the shoulders, and giving
internally one fluidrachm of the following compound, three times a
day, and half a fluidrachm in the intervals, whenever the cough
proved troublesome : Take of the tincture of Lupulin, tincture of
Scullcap, each, one fluidounce, tincture of Hyoscyamus half a fluid-
ounce: mix.

Mastodynia, or a painful and distended condition of the breasts, is
very apt to attend pregnancy, especially with primiparse, and may
be owing to the rapid development of these organs and flow of
blood to them. When severe, relief is frequently afforded naturally

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AMERICAN ECLECTIC OBSTETRICS.

by a thin, colorless, serous discharge from the nipple. To relieve
congestion, and prevent inflammation, which are the principal indi-
cations, tepid fomentations may be applied, together with an ano-
dyne liniment, as a mixture of Oil and Laudanum; the bowels
must be kept free, and all pressure upon the breasts removed.

Muscular pain about the pelvis and hips, as well as the abdomen,
frequently accompany pregnancy ; the cause of these pains is sup-
posed to be owing to pressure on the anterior branches of the sacral
nerves; but this could only happen when there has been a descent
of the uterus, at the termination of utero-gestation, for prior to
this period the uterus is too much elevated for its inferior portion to
compress these nerves. As these pains are more common after
fatigue, they are probably dependent on an irritable condition of
the nerves of the painful muscles, and should be treated princi-
pally by rest. In severe cases, stimulating liniments may be rubbed
over the affected parts, and the back; and the pain of the abdom-
inal muscles may be frequently relieved by the use of a bandage.

Mania, or insanity, usually attacks pregnant females of a hyster-
ical disposition, or those who are hereditarily predisposed to it.
It may occur at any period of utero-gestation, from conception to
parturition, and as a general rule, is not so severe as that which occurs
in the puerperal state, and ceases with delivery. The treatment
must be principally moral, meeting any symptoms which present
themselves, according to their indications ; employing tonic means,
where debility is present; antispasmodics and sedatives, where
there is much nervous irritability ; and the means recommended
for plethora, should this exist. The application of cold to the head,
stimulants to the spine, and cups to the temples or back of the
neck, should always be employed, as may be indicated, to overcome
any local congestion. When the mania is acute, treat it in the
manner recommended for Puerperal Mania, which see.

Beside the several affections which have just been named, as
owing to nervous sympathy and deranged circulation, there will be
found certain changes in the mental condition of the patient; thus
she may become very despondent, or very irritable. The former,
when severe and obstinate, and accompanied with gradual loss of
health, may terminate eventually in puerperal mania; the latter
has nothing serious in its tendency, and disappears after delivery.
The first must be treated by moral as well as therapeutical means ;

DISEASES OF THE PREGNANT FEMALE.

163

the patient should be kept from all depressing circumstances, should
be led into cheerful society, where she will not hear of any wonder-
ful or fatal accidents having occurred to parturient women, and
should be exhorted to overcome the tendency to despondency as
much as possible; the therapeutical measures should be laxatives,
cold to the head, diuretics, etc., if plethora exist; and chalybeate
tonics when an ansemic condition is present.

The second should be treated by the use of the compound syrup
of Partridgeberry, or the Parturient Balm, keeping the bowels
regular, and should wakefulness be present, the powder of Ipecac-
uanha and Opium may be adminstered, or tincture of Aconite root,
tincture of Hyoscyamus, tincture of Gelseminum, etc. The patient
should take moderate, but regular exercise daily in the open
air, and the diet should be of a non-stimulant and non-heating
character.

Pruritus of the Vulva, Prurigo or itching of the Genitals, occurs
during the early months of pregnancy, and is sometimes very dis-
tressing; occasionally it continues during the whole period of
utero-gestation, and disappears immediately after delivery. It may
be caused by uncleanliness, acrid discharges, and frequently, accord-
ing to Dewees, from aphthous efflorescence of the vulva; at times,
it occurs without any known cause. In the treatment of this dis-
tressing symptom, means must be employed according to its sever-
ity, and pathological condition of the parts affected. In the greater
number of cases the officinal Borax Lotion, with Morphia, will
be found efiicient ; if much inflammation of the parts is present, a
weak solution of the Sesquicarbonate of Potassa, or of Nitrate of
Silver may be applied locally and as it subsides an astringent
infusion may be substituted, as of Geranium and Golden Seal; a
compress of lint or soft linen should be moistened with these appli-
cations, and placed between the labia immediately in contact with
the affected parts. In all cases the bowels should be kept regular,
and the parts well cleansed. Occasional tepid baths may be
employed with benefit, and sometimes the induction of diaphoresis
will produce a favorable result. Internally, but little means are
required; the compound syrup of Partridgeberry may be admin-
istered, or a pill composed of one grain each of hydro-alcoholic
extract of Black Cohosh, Ferro-cyanuret of Iron, and Sulphate of
Quinia, may be given three or four times a day. The officinal
compound Ointment of Bayberry applied on lint, I have found

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AMERICAN ECLECTIC OBSTETRICS.

highly successful in a number of cases ; and in others, the disease
has disappeared as if by magic, upon the local application of a
lotion composed of a saturated aqueous solution of Sulphurous
Acid Gas one fluidounce, and rain-water three fluidounces. The sat-
urated solution may be made by passing a stream of the gas through
water, until this is saturated. Wet a pice of lint or linen with it
and apply to the part.

CHAPTER XVIII.

DISEASES OF THE PREGNANT FEMALE Continued.

The symptoms or affections originating from compression of the
enlarged uterus upon neighboring organs are several. (Edema, or
serous infiltration into the cellular tissue of various parts of the
body, will be first noticed. It may occur in the early months of
pregnancy, but is most common in the latter months, and is gener-
ally attributable to pressure of the enlarged uterus upon the blood-
vessels of the pelvis, thereby interrupting the circulation, and finally
resulting in effusion. It is not, however, always produced from
this cause, as frequently the size of the uterus bears no proportion
to the extent of the cedema, but is usually small ; and, again, we
frequently find the uterus enormously distended, either by excess
of liquor amnii or plurality of children, without any accompanying
cedema. In those instances where the swelling is caused by uter-
ine pressure, it is mostly confined to the lower extremities, but
where it spreads over the whole body, it is due to plethora, or renal
congestion, which may be known by the presence of albuminaria,
and either of which is unfavorable. Convulsions are very apt to
succeed cedema from these latter causes. Ordinarily, no pain
accompanies this affection, yet, occasionally, it is very painful.
Where the swelling is confined to the feet and ankles, quickly dis-
appearing on assuming the recumbent position, but little treatment
is required; but where it becomes so great as to render the recum-
bent position almost impossible, from dyspnoea, or where it is com-
plicated with effusion into any of the important cavities of the
body, it becomes of a serious nature, and requires energetic treat-
ment. In the milder cases, when confined to the lower extremities,
and where treatment is required, relief may be afforded by the

DISEASES OF THE PREGNANT FEMALE.

165

administration of laxatives, with cold applications to the (Edema-
tous part, at the same time supporting the limbs with a bandage
well applied. In severe cases, purgatives and diuretics will be ben-
eficial, and it will often become necessary to induce premature
labor as the only means of saving the patient's life, who can noj:
possibly live up to the full period, with an increasing infiltration.
When oedema is not dependent upon some important organic lesion,
it usually disappears after parturition. WhenYenal congestion is a
cause of the effusion, in addition to the above treatment, cups may
be applied over the region of the kidneys, and, if obstinate, a dis-
charge may be maintained from this region by means of an irrita-
ting plaster. Puncturing and scarification of the cedematous limbs
are advised by some authors, but they should not be attempted, as
they are most usually followed by gangrene.

When by pressure of the enlarged uterus upon the pelvic blood-
vessels, the circulation within the lower extremities is obstructed,
it gives rise to a varicose condition of their veins. This difficulty is
a frequent accompaniment of the latter months of utero-gestation,
and is more apt to occur in women of an advanced age, than in
young females. As they are owing to the impeded circulation in
the extremities, their cure can not be effected until the cause is
removed, when they usually disappear spontaneously. Sometimes,
they continue after delivery, gradually increasing, and on each sub-
sequent pregnancy augmenting considerably in size, forming tumors
which are more or less painful, embarrassing the movements of the
female, and often terminating in obstinate ulcerations. Rupture
of these veins is the principal accident to fear, as it may prove
fatal, and the practitioner's treatment should be especially directed
to a prevention of its occurrence. The patient should not be long
at a time on her feet, but should keep in a horizontal position, with
the dress loose, and the employment of properly graduated pres-
sure over the veins by means of bandages, or elastic stockings.
The bowels should be kept free, the diet spare, and the bandages
may be kept moistened with cooling applications, especially in
severe cases. If the varices are situated in the genital parts, as the
vulva or vagina, compresses moistened with cooling lotions may be
applied, and occasionally the application of leeches on the adjacent
parts may become necessary to prevent rupture, which sometimes
happens, especially at the time of parturition, during the passage
of the fetal head through the pelvic canal.

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AMERICAN ECLECTIC OBSTETRICS.

From a cause similar to the above, hemorrhoids, or piles, may be
produced, and more particularly if constipation be present. Occa-
sionally they are an attendant of diarrhea. They are similar in
nature and appearance to those occurring at other times, and
require the same local treatment, When slight, they may be
removed by producing regularity of the bowels by means of laxa-
tive medicines, among which I prefer the combination of powdered
Rhubarb and Bicarbonate of Potassa, with cold and astringent
applications to the parts. If pain or irritation exist, narcotic
ointments, as Poke, Stramonium, etc., may be applied with benefit,
and where the tumor protrudes externally, the pain and irritation
may be relieved by the application of an Elm poultice sprinkled
with Laudanum, or a cataplasm of Poke leaves, or Stramonium
leaves may be substituted. The removal of piles by an operation,
during pregnancy, is totally inadmissible and unjustifiable. Nor
can a perfect cure be expected until after parturition, when the
pressure has been removed by a return of the uterus to its non-
gravid condition. I have derived considerable benefit in this diffi-
culty from an ointment composed of Stramonium Ointment one
ounce, Alum two drachms, Sulphate of Morphia ten grains : mix,
and apply a small quantity on lint or cotton. Another valuable
local application may be prepared as follows: Take of Stramonium
leaves, Poke leaves, Tobacco leaves, of each, while green or fresh,
half a pound; dilute whisky two pints. Mix them together, and
boil down to one pint; then add Olive Oil one pint, and reduce by
means of a gentle heat to one pint, and strain. The tincture may
be prepared by displacement, instead of the above mode, and if
more than a pint be obtained, reduce it by heat. An infusion of
Solomon's Seal root, used by mouth and by enema, will likewise
prove useful in piles; it appears to exert a special influence over
the mucous membrane of the alimentary canal throughout, when
in an irritated or abnormal state. Occasionally the pain and irrita-
tion become so excessive that five or six leeches may be required
to remove the increase of blood accumulated in the part, and
thereby mitigate the suffering; but, as a general rule, their use
should be avoided as much as possible. Many other remedies have
been employed in piles with benefit, and others may suggest them-
selves to the mind of the practitioner, but whatever local means
may be used, it is of the greatest importance to keep the bowels
regular, the diet spare, but nutritious and easily digested, and avoid
too much exercise, or even long standing.

DISEASES OP THE PREGNANT FEMALE.

167

Should hemorrhage be present, it must be checked, especially
when considerable, or it may occasion miscarriage ; for this purpose
astringents, cold applications, and compression may be employed
A preparation composed of Stramonium ointment one ounce,
Styptic Powder (calcined Sulphate of Iron), two drachms, and
powdered Alum, one dra2hm, employed as a local application, and
introduced as far as possible into the rectum by means of the
finger or otherwise, together with the internal use, three or four
times a day, of a mixture of Rhubarb eight grains, Bicarbonate of
Potassa, powdered Rosin, each, four grains, will be found very val-
uable in all cases of hemorrhoids accompanied with hemorrhage.

Prolapsus ani is occasionally met with as a concomitant of piles,
or it may occur independently ; it is often attended with excessive
pain during an alviue evacuation, together with distressing tenes-
mus, and is usually produced by the same causes which occasion
piles, viz.: pressure. This symptom is exceedingly annoying and
distressing, and but little can be done toward a cure of it, until
after delivery is accomplished, when, as a general thing, the cause
being removed, a spontaneous cure is effected. Palliative measures
are all that can be employed, and I have found the most benefit to
accrue from the following course : Immediately after defecation,
which is the time in which the prolapsus commonly occurs, or at
any other time when it may happen, wash the prolapsed part in
cold water, return it, and immediately inject into the rectum about
an ounce of a strong infusion of equal parts of Solomon's Seal
root, Geranium root and Poke leaf; apply a compress of cotton
over the anus, and have the injectiou retained as long as possible.
Prolapsus ani is a very troublesome affliction during parturition, as
every pain is apt to cause a protrusion of the bowel, rendering it
irritable and most acutely sensitive.

Cramps of the inferior extremities, sometimes extending as high
as the upper pelvic region, are occasioned by pressure of the gravid
uterus upon neighboring nerves ; they may likewise be occasioned
by fatigue, constipation, or extension of ligaments. They are
6udden in their attacks, are occasionally very frequent and painful,
and mostly occur during the latter months of pregnancy. Friction
over the affected part, and change of position will ordinarily remove
them ; and when they are frequent in their attacks, relief can often
be afforded, and this disposition to frequency obviated, by attention
to the bowels, together with the use of the compound syrup of

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AMERICAN ECLECTIC OBSTETRICS.

Partridgeberry. I have used the following preparation, in many
instances, and it has proved an excellent palliative : Take of High
Cranberry bark two ounces, Scullcap leaves, Skunk Cabbage root,
each, one ounce, Capsicum, Cardamon seeds, each, half an ounce ;
bruise the articles and digest them for two or three days in two
quarts of Malaga wine. The dose is a tablespoonful three or four
times a day. The soreness caused by the cramps may remain for
some time after their cessation, and may be removed by rubbing
the parts with some camphorated oil, or the officinal compound
tincture of Camphor. Gelseminum may also be administered
with benefit.

The pregnant female frequently suffers from a deep-seated pain
in the right side, which most commonly manifests itself after the
fifth month ; it is unaccompanied by cough, or any febrile or inflam-
matory symptoms, and is attributed to the fundus of the uterus
pressing against the concave surface of the liver. It is not present
until after the ascent of the uterus above the superior strait — never
occurs in left lateral, or anterior obliquity of the uterus, but only
in right lateral obliquity, and is much relieved, after the eighth
month, by the falling or descent of the uterus into the pelvis.
Permanent relief can not be had until after delivery, yet when
severe, the female may derive considerable benefit from change of
position, standing, lying on the left side, stretching upward, and
leaning to one side; in addition to which the bowels should be
kept free by a powder composed of Rhubarb six or eight grains,
Leptandrin two grains, and Bicarbonate of Potassa four grains ;
mix for a dose, and repeat it two or three times a day. When the
pain is excessively severe, cupping will sometimes mitigate it.
The diet should be light and non-stimulant.

Jaundice, occasionally occurs during pregnancy, and is owing to
pressure upon the gall-ducts by the neighboring viscera, which are
compressed by the gravid uterus, in consequence of which there is
not a free escape of bile; it is more severe when it happens during
the latter months, and is usually attended with dyspeptic symp-
toms. But little can be done for this evil; though it is proper to
regulate the bowels, and attend to the diet. Should it remain
after delivery, it must be met with the appropriate treatment.

Females who have given birth to many children are sometimes

DISEASES OF THE PREGNANT FEMALE.

169

annoyed with a lax condition of the abdomen, in which the abdom-
inal parietes, from their excessive looseness, do not afford sup-
port to the enlarged uterus, thereby allowing it to fall in any
direction. The best treatment, in such cases, is a local application
composed of astringent and slightly-stimulant agents, together
with mechanical support by means of an appropriate belt or band-
age, and the patient should assume the recumbent position daily,
for three or four hours at a time.

In opposition to this, we frequently meet with a very rigid con-
dition of the abdomen, in which its parietes do not give way in pro-
portion to the gradual augmentation of the volume of the uterus.
This is most common among primiparse, occasioning much distress,
inconsequence of the tender and irritable condition of the parts,
the skin over which often cracks. This may sometimes be
relieved by rubbiug Sweet Oil, Almond Oil, simple ointment, etc.,
over the part, and if very painful or tender, it may be fomented
with Hops, Poppy heads, Elm bark, St. John's-wort, etc. Inter-
nal treatment is useless.

There are other symptoms occasionally met with during preg-
nancy, which are due to pressure, or nervous and vascular sympa-
thetic derangnment, and which deserve a passing notice. Thus,
in the latter months of pregnancy, females are unable to retain
their urine, which escapes upon the least exertion, and may or may
not be accompanied with tenesmus or a frequent desire to evacuate
the bladder; this incontinence of the urine seldom admits of relief
until the removal of the cause — the pressure of the bladder by the
enlarged uterus — by delivery; perhaps, some benefit may accrue
by giving support to the abdomen. It is a very annoying symptom,
but is by no means dangerous.

Occasionally, pustules around the genital organs may appear, or
vaginal mucous discharges of a whitish color, tinged sometimes with
green, or blood. These symptoms disappear after delivery, and
require no other treatment than cleanliness, frequently bathing and
injecting the parts with an infusion of Golden Seal, or of Golden
Seal and Geranium, or other similar combination. The practi-
tioner must be careful not to injure his patient's reputation as well
as his own, by pronouncing either of these as syphilitic, on too
slight grounds, for they are often the legitimate results of preg-
nancy.

Pressure of the uterus is apt to occasion congestion of various
12

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AMERICAN ECLECTIC OBSTETRICS.

organs, especially of the lungs or stomach, in consequence of
which hemoptysis or hematemesis may result from exudation of blood
from the mucous membrane. These hemorrhages may be treated
by laxatives, sedatives, astringents, and the means employed for
them when existing at other times. Should they, at the time of
parturition, become excessive, resisting the treatment employed,
the delivery should be hastened by artificial means.

There are likewise symptoms which occur during utero-gesta-
tion, depending upon an abnormal condition of the uterus or its
contents. Among the displacements of the organ, prolapsus or
descent, are the most common, and it usually takes place during the
first months, before the ascent of the uterus above the superior
strait ; the patient will complain of a bearing-down sensation, with
pain and uneasiness in the sacral region, and frequently in the
lower part of the abdomen. The prolapsus will be more or less
perfect according to the capaciousness of the pelvis, and the laxity
of the ligaments. Where there is an excess of pelvic dimension, a
sndden prolapsus may take place in an advanced stage of pregnancy,
from straining, over exercise, or some unusual exertion. This dis-
placement not only occasions abortion, but is frequently caused by it,
from the uterus being left in an inflamed or hypersemic condition;
it may also be produced by straining, debility, and whatever cir-
cumstances would give rise to it in the unimpregnated state. This
difficulty may give rise to very serious evils, and should be
promptly treated; the rectum and bladder should first be evacuated ;
the prolapsed organ should then be carefully placed in its proper
position, and retained there by a piece of fine sponge introduced
into the vagina, and the patient should maintain as much as pos-
sible the recumbent position, until the increased volume of the
uterus would prevent any further prolapse. The sponge may be
moistened with some astringent lotion, if desired, and should be
cleansed every two or three days. Any accompanying symptoms,
as debility, constipation, etc., must be met by appropriate treat-
ment. When we find an impaction of the uterus within the pelvis,
rendering its reduction impossible, abortion will have to be induced.

Retroversion of the gravid uterus, is sometimes met with, as well
as in the unimpregnated organ ; in this displacement, the fundus
is found backward, at or below the promontory of the sacrum,
while the os tincse is carried forward and upward, either upon, or
above the pubic symphysis, and the vagina being dragged along

DISEASES OF THE PREGNANT FEMALE.

171

with the os, its anterior wall will be likewise carried forward and
upward, while its posterior wall will be considerably depressed.
Retroversion of the uterus may come on slowly or suddenly, it
seldom exists in the latter months of pregnancy, and usually takes
place between the second and fourth months. It may be owing to
various causes ; a very common one is a retention of urine until
the bladder becomes enormously distended, which extending back-
ward and downward, thrusts the uterine fundus along with it in
the same direction ; or a large pelvis may predispose to this acci-
dent, but it is not an essential condition ; ovarian enlargement,
tumors, violent efforts, straining at stool, blows, falls, vomiting,
polypus, hydatids, etc., are each capable of effecting this displace-
ment under favorable circumstances. The symptoms accompany-
ing retroversion are, a partial or complete retention of urine, which
often takes place suddenly ; when it is partial there is a desire to
urinate frequently, the water passes off" in small quantities at a
time, but never in sufficient amount to empty the bladder, and
finally, it involuntarily dribbles away, and the enormous distension
of the bladder creates a chronic inflammation, or what is yet worse,
it may become ruptured. Defecation is also very difficult, the feces
being flattened and passing in small quantities; and both the
dysuria and difficult defecation are increased by any efforts at
evacuation. When retention of urine is present in the early
months of pregnancy, the practitioner should suspect retroversion,
and adopt the proper means to satisfy himself in relation to it.
In connection with these two prominent symptoms, there will be
an aching pain in the sacrum, thighs and pubes, with weight in the
pelvis and disagreeable bearing- down sensations. When retrover-
sion is suspected in the pregnant female, an examination should be
immediately demanded, for if it be not promptly attended to, it
may occasion the death of both the mother and child, as may be
readily imagined, when an enlarging uterus becomes impacted iu
the cavity of the pelvis, preventing micturition by its pressure upon
the urethra, causing irremedial constipation by compression of the
rectum, and intense suffering by pressure upon the anterior sacral
foramina and nerves. Upon an examination per vaginam, which
must in all cases be made, the uterine fundus will be found
depressed below the promontory of the sacrum, with the cervix
toward the bladder, and higher than the crown of the pubic arch;
in some instances, the os uteri may be found in its normal position,
with the fundus depressed, the cervix being bent or flexed at an

172

AMERICAN ECLECTIC OBSTETRICS.

angle, in which the uterus is shaped somewhat like a retort ; this
is termed retroflexion, and is not common in the pregnant condi-
tion. If this displacement be not relieved, the pains continue to
increase, vomiting takes place, with peritonitis, and the patient
dies from inflammation or sloughing ; and it must be remembered,
that the later the gestating period in which retroversion occurs,
the greater is the danger.

In treating a case of this character, before any attempt at reduc-
tion is made, the bladder must be emptied by means of a male
elastic catheter, bearing in mind that the displaced uterus, having
elevated the neck of the bladder, causes an elongation of the
urethra. Sometimes considerable difficulty will be experienced in
introducing the catheter, which may be overcome by pressing the
uterus backward, and thus liberating the urethra, until the instru-
ment has entered. Soon after the evacuation of the bladder it will
often be found that the uterus assumes its normal position without
further interference ; should this not take place, the rectum must
be unloaded by copious injections, as an accumulation of fecal mat-
ter within it, will very much interfere with the attempt to replace
the uterus properly. The patient is now to be placed upon her
face, or the operation may be performed while she lies on her left
side, and two fingers be passed into the posterior part of the vagina
along the curve of the sacrum, until they come in contact with the
presenting part of the depressed fundus, which must be pressed
cautiously and firmly upward and forward, in the direction of the
axis of the superior strait; for if the pressure be made in any
other course, no reduction can be accomplished. When the reduc-
tion is effected, the womb assumes its position with a sudden jerk,
and sometimes a clicking noise. Sometimes this attempt will fail ;
it will then be proper to introduce one or two fingers into the rec-
tum for the purpose of pushing the fundus upward and forward,
while a finger or two of the other hand enters the vagina, for the
purpose of bringing down or depressing the cervix, and all these
trials should be made steadily, cautiously and firmly. In very
obstinate cases, the patient may be placed on her knees, having the
pelvis elevated as high as possible, while the shoulders rest upon
the bed, table, or whatever she is placed upon, and in this position,
having the aid of gravitation, we may undertake the last named
manipulation ; this posture is a favorable one, inasmuch as it tends
to overcome tenesmus and bearing-down efforts.

Having accomplished reduction, the patient should be kept in a

DISEASES OF THE PREGNANT FEMALE.

173

recumbent state, until the ascent of the uterus above the promon-
tory, when its volume has so far augmented as to render any further
displacement of the kind impossible; and the bladder should like-
wise be emptied every four or five hours. Instances are sometimes
met with, in which, after the organ has been reduced, it will not
remain so, but falls over again upon the slightest exertion, and the
operation will have to be performed again and again before the
reduction will remain permanent. In these cases advantage has
ensued from the introduction of a thin gum-elastic bladder, of a
fusiform shape, into the rectum ; the large end of -this to be
introduced, after which it is to be distended with air, and con-
stantly worn by the patient, until no longer required; it admits of
easy removal at any time by permitting the inclosed air to escape,
and then withdrawing it.

The reduction of the uterus may only be partial, so that although
remaining in the pelvis, a part ascends, giving the organ a deformed
shape, still an attention to the bladder and rectum may enable the
patient to reach the full term; in these cases the labor may be
completed without artificial aid, though it may be tedious and
difficult.

Where retroversion has occurred previous to pregnancy, and the
organ is rendered almost immovable by adhesions, or where from
other causes, after a persevering attention to the bladder and rec-
tum, no permanent reduction can be obtained, it has been proposed
to induce premature labor as the only means of saving life; but
we must be cautious in a resort to this expedient, and should never
undertake it without the opinion of a second or even third
practitioner.

In anteversion of the uterus, the displacement is exactly contrary
to the last; the fundus pressing forward toward the symphysis
pubis, near the level of the superior strait, while the cervix is
thrown backward and upward, the os uteri looking toward the
hollow of the sacrum. This may originate from severe exertion
while the bladder is empty, and is more apt to ensue when the lig-
aments are in a relaxed condition — from blows, falls, tumors,
diarrhea, relaxed abdomen, fecal accumulations, etc. The symp-
toms are, a constant desire to pass urine, which is accomplished
with some difficulty and heat ; constipation is frequently present,
with pelvic heaviness, hypogastric pain, and a distressing, dragging
sensation, which is augmented by standing or walking. It is

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AMERICAN ECLECTIC OBSTETRICS.

rarely present during pregnancy, and when it does occur is not so
serious as retroversion. The treatment is to elevate the fundus
and pull down the cervix with a finger, or hook, and afterward, if
required, a bandage may be worn, with a compress over the pubes ;
the bowels should be kept open, but the urine should not be passed
too frequently.

An aqueous discharge, of a limpid, or yellow color, sometimes
takes place during pregnancy, being variable in quantity, at times
passing by drops, and again occurring suddenly and in large
amount. It is called hydrorrhea, or, false waters. Usually this is
not a serious affection, but occasionally uterine contractions of a
severe character accompany it, which, if not overcome, will result
in the premature expulsion of the uterine contents. As regards
the source from which this fluid originates, we have no satisfactory
evidence; authors vary in opinion concerning it, some considering
it to be the result of an uterine dropsy, others to a transudation of
the amniotic fluid through the membranes, some again to a rupture
of the allantois, or rupture of the chorion and caduca, etc. Most
generally, the woman goes on to the full term of utero-gestation.
Where there is danger of miscarriage, the bowels should be kept
in a soluble condition by mild laxatives or injections, the patient
should be enjoined to keep in a state of repose, and sedatives must
be administered, among which I prefer the officinal compound
powder of Ipecacuanha and Opium. As soon as any danger of
premature labor has passed away, the patient should take the corn-
pound syrup of Partridgeberry, for the purpose of imparting
tonicity to the reproductive organs, in connection with chalybeates
if anaemia be present. When a symptom of this character attacks
a pregnant female, the practitioner should be careful to ascertain
the condition of the -bladder, as not unfrequently a discharge of
urine may be mistaken for it.

Not unfrequently the uterus is attacked with spasmodic action —
the organ may be felt rapidly moving from side to side, with fre-
quent convulsive movements, and will speedily induce premature
labor if not relieved. I find it the best treatment in these cases,
to evacuate the rectum by enema, after which inject a fluidrachm
or two of Antispasmodic tincture mixed with a little tepid water,
into the rectum, and cause it to be retained there as long as possi-
ble, while internally the patient may take a teaspoonful or two of

DISEASES OF THE PREGNANT FEMALE. 175

I

tincture of Gelseminum, with ten or twenty drops of tincture
of Black Cohosh. Anodyne liniments may also be rubbed on the
abdomen.

The impregnated uterus is sometimes attacked with rheuma-
tism, commonly produced by the same causes which give rise to
rheumatism of other parts. It is most common to those of a
rheumatic diathesis, and is frequently a metastasis of the pain from
some other part. The symptoms are pain, augmented sensibility
of the uterus, which may be limited to only a part of the organ,
or extend over the whole of it, no contractions, pressure often
increases the pain, which may extend into the loins, groins, and
thighs, or which may suddenly be translated to some other part of
the system. There is a constant desire, or tenesmus, to evacuate
the bladder and rectum. To remove this condition, dry-cupping
may be employed over the lumbar and sacral regions, with sina-
pisms to the wrists ; or, when the patient is subject to rheumatism,
the sinapism should be applied to the parts in which it is most
commonly seated. The bowels should be kept regular, and
internally a pill composed of hydro- alcoholic extract of Black
Cohosh one grain ; Quinia half a grain ; and extract of Aconite
one-eighth of a grain, may be administered every one, two, or
three hours. In many cases, diaphoresis, induced by the adminis-
tration of compound tincture of Virginia Snakeroot, will be
followed by prompt relief. Benefit will frequently follow the
exhibition of tincture of Gelseminum eight parts; tincture of
Aconite one part : dose, half a fluidrachm, repeated every hour or
two, until the peculiar influence of the remedy is obtained. This
will be found a valuable agent in all rheumatic and neuralgic
affections.

The movements of the fetus in utero, are sometimes very violent,
or turbulent, not only occasioning alarm to the mother, but much
uneasiness, a sense of sickness, with general nervous agitation,
sleeplessness, febrile symptoms, and often local pain. This may be
owing to an irritability of the nervous system, or to some preter-
natural susceptibility of the uterus. It may be removed by an
attention to the bowels, and the administration of a combination
of Cypripedin, Scutellarin, and Cimicifugin ; the compound syrup
of Partridgeberry will frequently prove beneficial ; and when
obstinate, a few doses of the compound powder of Ipecacuanha

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AMERICAN ECLECTIC OBSTETRICS.

and Opium may be given. However, the practitioner should bear
in mind, that narcotics should be employed as seldom as possible,
during pregnancy, on account of their deleterious influence upon
the nervous system of the fetus. Cimicifuga, Caulophyllum,
Cypripedium, Scutellarin, Valerian, Lupulin, Symplocarpus, etc.,
should be used in preference.

Dropsy of the ovum, usually takes place during the early months,
and may be suspected by an unnaturally great increase in the size
of the abdomen, which comes on suddenly, thereby differing from
the gradual enlargement in ascites, and which is rendered still
more certain when the pregnancy is positively determined. It is
frequently, however, very difficult to form a correct diagnosis, and
some of our oldest and most experienced practitioners have been
mistaken in relation to it. Abortion is the common result, the
fetus generally perishing before this accident occurs, especially if
the collection of the fluid is great ; and should it be born alive, it^
seldom survives a few days, or weeks at farthest. The only treat-
ment, in this affection, is strict attention to the health of the
female, and an absolute avoidance of the operation of paracentesis ;
for no practitioner is justified in performing this operation on' a
female who affords the smallest possible suspicion of pregnancy ;
at least until a sufficient time h is elapsed for its determination by
the positive signs, as revealed by auscultation, ballottement, etc.
When the quantity of fluid is enormous, giving rise to serious
consequences, the propriety of inducing premature labor by
evacuating the amniotic liquid, may then be considered. Hemor-
rhage and abortion will be treated of in the following chapters.

The accidental concomitants of pregnancy, are hernia, tumors,
syphilitic affections, calculus, deformed pelvis, and extra-uterine preg~
nancy; the latter two have already been treated upon, the others
require no especial consideration at this place ; they will be
again referred to under the head of labor. The treatment for
syphilitic affections will be the same as pursued under other cir-
cumstances, independent of pregnancy.

HEMORRHAGE AND ABORTION.

177

CHAPTER XIX.

HEMORRHAGE AND ABORTION.

When the fetus is capable of continuing its existence, inde-
pendent of any uterine connection, it is said to be viable ; and the
period of this viability, though not precisely fixed, is generally
admitted as early as at the commencement of the seventh month.
There are, however, a few instances on record where children, born
as early as the commencement of the sixth month have been
reared, but these may be considered as the exceptions to the gen-
eral rule. A fetus may move at birth, but this does not constitute
viability. In cases where it is non-viable, or incapable of sustain-
ing an extra-uterine existence, that is, previous to the seventh
month, and is expelled from the uterus, owing to any cause what-
ever, an abortion is said to have taken place. Its expulsion at any
time between the seventh month and full term, is a premature
delivery ; and the term miscarriage is popularly applied to either of
these, indiscriminately, and generally conveys an idea of loss of
offspring previous to the ninth month.

As hemorrhage and abortion are intimately related, being gen-
erally dependent on, or connected with each other, I will consider
them under one head. Hemorrhage may take place at any period
of pregnancy, and is owing to a greater or less detachment of the
ovum from the uterus, and the more extensive the detachment, the
greater is the necessity for, or disposition to abortion. In the
earlier months, life is seldom endangered by hemorrhage, in con-
sequence of the smallness of the uterine bloodvessels, which do
not admit of a large and rapid discharge of blood ; but in the
latter months, where these vessels have become much augmented
in size, there is always danger from the hemorrhage which may
then occur. It should be stated here, that women, laboring under
hemorrhage in the earlier months, are occasionally lost, the flooding
obstinately resisting all treatment ; this is more usual with debili-
tated or ansemic individuals, especially those who have previous
discharges, with large loss of blood.

Abortion, may be spontaneous, accidental, or designed, and may
occur at any time prior to the seventh month, but more frequently
about the third month, and generally at a period coincident with

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AMERICAN ECLECTIC OBSTETRICS.

menstruation ; this is undoubtedly owing to the delicate connection
existing between the ovum and uterus at this time, whereby a sep-
aration of the former may ensue more readily from even slight
causes than in the latter months, when this connection is more per-
sistent. Abortion is not usually a serious accident, as many females
abort several times, successively, and few women who bear offspring
pass through their menstrual life without aborting one or more
times. The principal dangers are from excessive hemorrhage, or
the constitutional injury inflicted by a series of successive abortions.
The causes of this accident are numerous, and have been divided
into constitutional, or depending upon the condition of the maternal
health ; ovuline, or attributable to some disease of the ovum ;
uterine, or originating from an abnormal state of the uterus and its
appendages ; and accidental, or owing to circumstances not imme-
diately connected with the condition of the uterus, ovum, or mother.

No particular class of females are especially liable to abortion ;
it occurs among those who enjoy the idle, sedentary, luxurious
habits of fashionable life, and among those who are obliged to earn
their daily subsistence by hard labor ; the most robust may abort
as well as those of a delicate and nervous disposition ; though it
may, probably, be more frequently observed among those who
neglect an attention to the rules of hygiene. Authors state that
plethoric females, those who are nervous or irritable, or extremely
susceptible to external impressions, and those of indolent habits,
abort more frequently than others; it has likewise been stated
that abortion may occur as an epidemic. The constitutional causes
are tuberculous diseases, as scrofula, phthisis, and recent cutaneous
affections, epilepsy, hysteria, abdominal tumors, leucorrhea, diar-
rhea, dysentery, constipation, strangury, or, measles, scarlatina,
typhoid fever, small-pox, and other acute diseases. Syphilis is
likewise a common cause. Among these causes, when they occur,
probably, syphilis, epilepsy, small-pox, and scarlet fever, are the
most certain. Ascarides, piles, or other diseases of the rectum, as
well as of the bladder, by the irritation they communicate to the
uterus, may likewise become causes.

Females, during pregnancy, or even after a recent confinement,
should never be vaccinated, because in either case it exposes them
to great hazard ; this is a point to which especial attention should
be paid, not only on account of the abortion which would very
probably follow, in the first condition, but, in either, violent fever

HEMORRHAGE AND ABORTION.

179

or inflammation of the veins, might be produced, resulting in
death.

The ovuline causes are numerous ; thus, the fetus may be affec-
* ted with the parental disease, as measles, small pox, scarlatina,
etc., which may either occasion its death, or cause its attachment
to the uterus to become so delicate as to render abortion unavoid-
able. Syphilitic disease may be communicated to the ovum by the
male parent, as well as the female ; and a seminal fluid vitiated by
debauchery, or having its vitality enfeebled by age, may also give
rise to an unhealthy embryo, the result of which will be an abor-
tion. Atrophy, also hypertrophy of the placenta, may so debili-
tate its connection with the uterus as to become a cause of this
accident. An eftusion of blood between the placenta and uterus,
termed by M. Cruveilhier placental apoplexy, may separate the pla-
cental connection, and give rise to abortion ; placentitis, hydatids,
or fatty degeneration of the placenta, rupture of the umbilical
vein, etc., will also produce it. Whenever the fetus is dead, from
whatever cause, it becomes a foreign body, excites uterine contrac-
tion, and must inevitably be expelled, though frequently some
time may pass between its death and expulsion. Other diseases of
the embryo or its appendages may likewise occasion abortion.
Indeed, it is supposed, that the most common causes of this acci-
dent, are those referable to the condition of the ovum.

Among the uterine causes are, prolapsus, retroversion, antever-
sion, adhesions, uterine irritability, uterine congestion, fibrous
tumors, polypus, cancer of the cervix, diseases of the tubes or
ovaries, ulceration of the cervix, corroding ulcer, etc. Madam
Boivin found that, among a great proportion of those females who
habitually aborted at a regular period of utero-gestation, dissections
revealed uterine adhesions to the bladder, rectum, or other neigh-
boring organs ; of course, if these adhesions are considerable, there
can be but little expectations of cure.

The accidental causes are falls, blows, coitus, severe exercise, lift-
ing heavy weights, rough motion on horseback or in carriages, or
violent concussion of the body from jumping; and the membranes
of the ovum may be so frail as to rupture upon a very slight com-
pression of the uterus, occasioned by coughing, sneezing, extract-
ing a tooth, or straining at the stool. Abortion is also occasioned
by emesis, drastic purgation, tight-lacing, terror, grief or excess of
joy, together with the criminal means frequently employed for this
purpose. It is unnecessary to enter into a detailed relation of

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AMERICAN ECLECTIC OBSTETRICS.

these causes, as they can seldom be obviated by the practitioner,
whose principal efforts will be directed toward preventing their
results from becoming dangerous. Some women abort from the
slightest causes, while with others again, the most serious accidents
produce no influence of this kind. It is stated that abortion has
been caused by the mere smelling of a pungent odor, but I pre-
sume such instances must be very rare. Among newly-married
persons, abortions frequently occur from the abuse of coition, and
this will likewise prove a very fertile cause of the accident among
child-bearing females at any period, especially when they have
some displacement or disease of the uterus. As a general rule it
may be observed, that when the ovum is healthy, and its placental
connection is firm, the production of abortion in a pregnant female
will be found very difficult to effect, except it be attempted by
some mechanical means, when it will be apt to assume its more
serious character ; but if the ovum be diseased, the tendency to
abort will be in proportion to the influence of the disease upon it,
and its placental connection with the uterus.

Abortion is undoubtedly produced by continued lactation during
pregnancy ; and with many females, conception, as well as men-
struation, is retarded while the child continues to suck. But when-
ever the menses appear during suckling, the child should be imme-
diately weaned, both for its own advantage as well as that of its
mother ; and the same course should be adopted when pregnancy
happens. Frequently, a threatened abortion may be checked, and
the female be enable to reach full term, by immediately weaning
the child upon the first appearance of pain or bloody discharges.

The symptoms of abortion are very much modified by the causes
which produced it, and the period of pregnancy at which it occurs.
If it happens during the first days of pregnancy, it is accompanied
by little or no pain, and is often mistaken by the female for a diffi-
cult menstruation ; and the ovum which usually passes away entire,
and accompanied by a greater or less amount of blood, is looked
upon merely as a coagulum or clot. When the pregnancy is more
advanced, and especially when the abortion proceeds slowly and
gradually, various premonitory symptoms may present themselves,
as a feverish or irritable condition of the system, loss of appetite,
nausea, cold extremities, swelling of the eyelids, with lividity, men-
tal depression, intermittent pains in the loins, a sensation of weight
about the vulva, frequent desire to urinate or defecate, and flac-

HEMORRHAGE AND ABORTION.

181

ciditj of the breasts; the pains continue to increase in frequency
and force ; they extend over the abdomen, running toward the
coccyx, and finally assume the characters of true uterine contrac-
tions. A sanious and bloody vaginal discharge takes place, and, as
the pains continue, the dilatation of the os uteri progresses, the
membranes protrude, become ruptured, the liquor amnii escapes,
and, sooner or later, the ovum, either entire of not, is expelled.
As all these symptoms, with the exception of rupture of the mem-
branes, may occur in pregnancy without any subsequent abortion,
the practitioner must be guarded in his diagnosis, unless he knows
positively that the fetus is dead.

Most frequently, however, there are no precursory or constitu-
tional symptoms ; the first sign being the hemorrhage, which is
more or less abundant, and is followed by a cessation of the fetal
movements, pains, and expulsion of the fetus. If the fetus is dead,
or the liquor amnii has been discharged, abortion will almost cer-
tainly take place, sooner or later, though no time can be positively
determined after the death of the fetus, for its expulsion.

Between dysmenorrhea and abortion there is considerable
resemblance in the character as well as the seat of the pains ; both
are intermittent, and both cease after expulsion of the uterine con-
tents ; hence, it becomes the accoucheur to proceed cautiously in
forming his diagnosis. He must first endeavor to ascertain whether
pregnancy has taken place ; failing in this, he must inquire into
the character of the previous menstruations, whether they were
painful, accompanied with much hemorrhage, etc. And he should
never fail to examine all the discharges, especially the clots, if
they have not been thrown away, breaking them down between
the fingers, and among which he may discover the entire ovum, or
only a portion of it ; and every practitioner should perfect himself
in a knowledge of this kind, not only by an examination when
ever the opportunity occurs, but also by procuring, if possible, ten
or twelve specimens of ova at various periods of pregnancy, and
preserving them, so as to accustom the eye to a familiarity with
them. If he ascertains that the former menstruations were
healthy, and that between the present difficulty and the last
menstruation, one or two months have been passed without any
discharge, these are strong grounds for suspecting abortion ; if
pregnancy exists, abortion is undoubtedly in progress. The blood
in dysmenorrhea is menstruous, while that in abortion is san-
guineous, and escapes in larger quantities than is usual to the

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AMERICAN ECLECTIC OBSTETRICS.

catamenia. The finger should likewise be introduced into the
vagina for the purpose of ascertaining the condition of the cervix,
and if its orifice be found sufficiently dilated to admit the end of
the finger, the diagnosis becomes more certain.

The diagnosis of abortion is more positive as the period of utero-
gestation advances, because the development of the uterus can
then be readily ascertained, the pains will be more violent, the
hemorrhage more abundant, and the dilatation of the os uteri
more easily detected. After the fifth month the death of the fetus
may also be more positively ascertained by auscultation, which
will fail to detect the sounds of the fetal heart, and if it has been
dead for a few days, there will be found an emaciation and flac-
cidity of the breasts, a diminution in volume of the abdomen, with
weight in the hypogastrium, dragging sensations about the loins,
and cessation of the fetal motions which were previously observed
by the female. In the early months of pregnancy, if nausea,
vomiting, or other sympathetic irritations connected with this
condition, and which are present with a patient, become sud-
denly suspended, it affords grounds for suspicion of approaching
abortion.

The prognosis of abortion varies according to its cause, as well
as the period in which it occurs ; females who abort are always
exposed to more danger than when delivery takes place naturally
at full term. In a few cases, death takes place during the accident^
but more commonly no immediate fatal effects happen, though
they are very apt to ensue as secondary results, being the conse-
quence of some chronic disease of the uterus, ovaries, etc., pro-
duced by the abortion. Females at full term are more subject to
acute maladies, which often prove immediately fatal, while the
serious results of abortion more commonly manifest themselves at
a remote period ; yet grave consequences may occur speedily under
either of these conditions. Abortion is very generally unfavorable
to the fetus, because its expulsion happens during its stage of non-
viability, and its death must inevitably take place ; or, the abor-
tion may have been determined by its death. In this latter case,
the fetus, acting as a foreign body, excites the uterus to contrac-
tions; but this effect may not take place for weeks and even
months after its death.

Abortion occurs with more difficulty, and is attended with more
danger, after the second month of pregnancy than before, on

HEMORRHAGE AND ABORTION.

183

account of the increased size of the ovum, and the unfavorable
condition of the cervix to dilatation; and the more advanced the
pregnancy, the greater is the danger from hemorrhage. Probably,
abortions occurring during the third and fourth months of preg-
nancy, are, as a general rule, more dangerous than at any other
period. If the hemorrhage is profuse, abortion will be very apt
to follow, though the practitioner must bear in mind, that large
and frequent hemorrhages may occur, and yet pregnancy continue
to the full term. If the pains occur at regular intervals, with
dilatation of the os uteri, and protrusion of the membranes, the
abortion almost always follows ; and if the membranes be rup-
tured, it will certainly occur; the death of the fetus will likewise
positively determine it, though a few instances are related of an
opposite character.

If the abortion be produced by constitutional, accidental or
mechanical causes, it is usually more violent or alarming in its
results, than when owing to the uterine or ovuline. When it
occurs during acute attacks, as measles, erysipelas, scarlatina,
small-pox, typhus, etc., being the result of the severity of the
attack, it is very apt to prove fatal, especially when it takes place
before a mitigation or cure of the acute disease has been effected.
When produced mechanically, the principal danger is from hem-
orrhage, peritonitis, or metritis. Usually, the more slowly the
abortion comes on, the less danger is there to fear from hemor-
rhage, though the constitutional effects are more to be dreaded, than
when it is accomplished with rapidity. Previous abortions always
exert an unfavorable influence upon subsequent pregnancies, pre-
disposing to a similar accident, and which, of course, requires the
especial attention of the practitioner.

The ovum, in an abortion previous to the third month, is usually
expelled entire, but after this period it commonly proceeds as at
full term, the liquor amnii being first discharged, followed by the
embryo, and sooner or later by the placenta. At the third and
fourth months, the placenta lias considerably augmented in size,
and has likewise formed close adhesions with the uterus ; and this
latter organ, though it may have acquired a degree of contractile
power sufficient to expel the ovum, does not possess the .con-
tractility of tissue as developed at full term, and is frequently
incapable of overcoming the attachment existing between it and
the placenta. In an abortion at this period, a partial evacuation

184

AMERICAN ECLECTIC OBSTETRICS.

of the uterine contents, is very apt to be followed by a closure of
the os uteri, and a cessation of the symptoms, leading the practi-
tioner to believe that the abortion has happily terminated; but
after several days the hemorrhage, generally preceded and accom-
panied with pains, again appears with increased severity, and if
the cause be not removed, the patient dies. The cause, in this
instance, is a retained placenta and membranes ; the utero-pla-
cental adhesions having been overcome, hemorrhage, and some-
times copious hemorrhage, follows the separation of the placenta
from the uterus, which remains detached in the uterine cavity,
irritating the uterus and preventing its complete contraction,
thereby promoting an increased hemorrhage, and causing a fatal
termination, if the patient be not relieved by art. And whenever
hemorrhage occurs, several days subsequent to an abortion, the
practitioner should always suspect the. presence of the placenta
and membranes within the uterus, without regard to the state-
ments that may be made to him, affirming that these have been
expelled. He should at once make a vaginal examination, when
he will probably find a partially dilated os uteri, with a portion of
the placenta protruding. Should the placenta be only partially
detached, the os may be slightly dilated, but without protrusion of
the placenta, depending however upon its situation and extent of
separation. Occasionally, the placenta decomposes, the uterine
discharges become fetid, absorption of the putrid matter takes
place, and an irritative fever ensues, requiring all the skill of the
practitioner to overcome, or to avert its fatal effects. Putrefaction
of the dead fetus takes place only when the membranes are rup-
tured, which admits the air into the cavity of the uterus; decom-
position without putrefaction ensues when the membranes are
entire. Absorption of the placenta has been observed, both after
an abortion, as well as after a natural accouchement. Some-
times an effusion of blood into the placenta may occur, and by
imparting to it a kind of organization, produce what are known
as " fleshy moles."

The TREATMENT varies according to the symptoms which
are presented, the principal indications being, to prevent the abor-
tion if possible, and when this can not be effected, to assist the
expulsion of the uterine contents, and likewise to remedy any sub-
sequent accidents. In all cases of abortion, the practitioner should
examine the condition of the cervix, except in instances where the

HEMORRHAGE AND ABORTION.

185

death of the fetus has been positively ascertained; if it be but
slightly dilated, unfavorable to the speedy expulsion of the ovumj
and if the hemorrhage be not too threatening, an attempt may be
made to check its further progress; but if it be dilated and
attended with considerable hemorrhage, means must be adopted
which will favor the speedy expulsion of the uterine contents. In
a great number of cases whether abortion ensues or not, all the
treatment required will be, rest in the recumbent position, per-
fect quiet, cooling drinks, and light diet, with an occasional dose
of the compound powder of Ipecacuanha and Opium, say four or
five grains repeated every two, three, or four hours, for the pur-
pose of subduing the pains. But where this course does not
speedily effect a mitigation of the symptoms, a blister should be
applied over the sacrum ; indeed, I seldom attend a case of threat-
ened abortion in its early stage, without having a blister or sina-
pism placed over this part. If the blister be employed, mucil-
aginous diuretics should be administered internally to overcome
any tendency to strangury, as an infusion of equal parts of Pars-
ley and Marshmallow roots. Should any displacement of the
uterus, or other affection exist, it must be treated as named here-
after. Nauseating with a preparation composed of three or four
parts of the tincture of Lobelia, and one of tincture of Opium,
has been recommended and successfully employed in some cases,
but I deem it an inferior method to the one above named;
although it may be used should that fail. Care is required not to
cause emesis, which might render the abortion inevitable. The
administration of Stramonium seed has been highly spoken of,
but I have never seen their action in such cases, and can therefore
say but little about it. If the hemorrhage be slight, it may not
require any especial attention, but when it is considerable, efforts
should be made to check it. For this purpose, cloths wet in cold
vinegar and water, or ice may be applied to the hypogastrium and
pudendum ; but the application of ice within the vagina, or cold
vaginal injections, recommended by some authors, should be used
with great caution, lest they produce the accident we are attempt-
ing to avert. In connection with these, internal means must be
used, a few drops of the oil of Erigeron, or oil of Erechthites may
be given, in mucilage or on sugar, every ten, thirty, or sixty
minutes, according to the severity of the hemorrhage; or, a pow-
der composed of burnt Alum and Sulphate of Iron, three grains,
Capsicum one grain, may be administered as often as the urgency
13

186

AMERICAN ECLECTIC OBSTETRICS.

of the symptoms demand; the burnt Alum and Sulphate of Iron,
form a valuable hemostatic, and may be made by mixing together
two parts of Sulphate of Iron and one of Alum, and exposing
them to heat in a stone or clay dish, until the mixture assumes a
reddish color. Other astringents may be employed in the absence
of those named. An agent in common use as a hemostatic, is pow-
dered alum and nutmegs ; Prof. Meigs recommends it in the pro-
portion of five grains of the former to one of the latter as a dose,
to be repeated every half hour or hour.

Should these means fail to arrest the hemorrhage, and there is
no doubt on the mind of the practitioner, but that the expulsion
of the ovum must take place, the tampon or plug should be
employed. This consists of pieces of linen cloth, muslin, silk, etc.,
about three or four inches square, which are separately introduced
into the vagina, until it is completely filled and distended ; these
are to be kept in place by a napkin or bandage, and may be allowed
to remain for six or twelve hours, but never to exceed twenty-four.
Sometimes sponge is used, but I think it inferior to the pieces just
referred to. It must be especially borne in mind by the practi-
tioner, that the tampon is never, under any circumstances, to be
used after the fifth month of pregnancy; because, the uterine
capacity having become much augmented, its cavity may become
distended with blood or coagula, and cause a fatal result. Previ-
ous to the fifth month, however, it is incapable of containing an
amount of blood sufficient to prove fatal from a concealed hemor-
rhage. Upon the removal of the tampon, a coagulum may be
observed attached to its upper part, in the center of which the
ovum, or its remains will generally be found. Should the presence
of the tampon induce dysury, the bladder must be evacuated by
means of a catheter; and during the whole treatment the female
should be kept in the recumbent position, and not allowed to arise
until all danger from hemorrhage is over. The tampon ought
never to be used when there is any possibility of checking the
abortion, as it almost always increases the tendency to abort, in
consequence of the irritation of the cervix produced by its pres-
ence, having extended to the fundus ; beside, the external discharge
of blood being suppressed, it continues to be effused internally,
gradually separating the ovum from the uterus, until it finally
passes off, surrounded with a compressed coagulum.

Females who habitually abort in the early months of pregnancy,
should, after the symptoms of abortion have been removed, be

HEMORRHAGE AND ABORTION.

187

advised to remain in the horizontal position, avoiding all fatigue
and violent exertion, until the uterus has risen above the superior
strait of the pelvis. The employment of the lancet in cases of
abortion, is recommended by some authors, but I can not perceive
its utility ; the detachment of the placenta from the uterine wall,
which is the cause of the hemorrhage, can not certainly be rem-
edied by a loss of blood from some other part of the system, for
in all the cases which I have witnessed treated by blood-letting,
the separation continued to progress with augmented hemorrhage,
and the only result gained was a degree of debility and disposition
to disease, on the part of the female, probably greater than would
have resulted had the use of the lancet been omitted. It is true,
that in consequence of the prostration of nervous and muscular
force effected by its use, it may overcome rigidity of the cervix,
and favor the dilatation of the os uteri, when the fulfillment of
these indications is desired, but then we have remedies which
produce the same results without disposing a part or all of the
constitution to any of the after disastrous consequences so common
to blood-letting, as, Lobelia, and still better, the tincture of Gel-
seminum, from the relaxing influences of either of which, the
patient will speedily recover. I am aware that bleeding in many
cases may arrest or modify the expulsive contractility of the
uterus, but it is effected at a great expense to the constitution of
the patient, and is by no means a safe or desirable method of treat-
ment ; Opium, either alone, or combined with Lobelia, Gelseminum,
or Scullcap, will not only produce the same results, but will succeed
in cases where bleeding fails. For the purpose of equalizing the
circulation, it has been advised by some accoucheurs to bathe the
lower extremities of the female, in warm water ; with some
patients this course may be attended with benefit, but it should
always be employed with caution, as among many women it will
be found to facilitate the abortion ; it is only in hemorrhage after
the expulsion of the ovum where much advantage will be derived
from this local bathing.

If by the means employed the abortion is not prevented, or if it
be so far advanced that no hope for checking it can be reasonably
entertained; the pains increasing together with the hemorrhage,
the os uteri gradually dilating, and the ovum being within reach
of the finger, all that the practitioner can do is to patiently await
the efforts of nature, and carefully watch the hemorrhage ; as a
general rule, any artificial interference is highly improper, and

188

AMERICAN ECLECTIC OBSTETRICS.

might give rise to serious consequences. The practitioner must be
very careful not to rupture the membranes in the early months,
for the purpose of facilitating expulsion, as it is always desirable
that the ovum be expelled entire, for when the membranes are
retained after the discharge of the fetus, there is danger from hem-
orrhage; and when, in cases of such retention, it is found that the
contractions of the uterus are insufficient to separate and expel the
membranes, agents may be administered which will promote these
contractions, as Black Cohosh root, Blue Cohosh root, or Ergot;
or these agents may be combined in equal proportions. The fresh
inner Bark of Cotton root, in strong infusion, will generally excite
the uterus to energetic action. If this does not produce the desired
effect, and the hemorrhage continues unabated, it will be proper for
the practitioner to introduce a finger within the canal of the cervix,
as far as possible, then bend it so as to resemble a blunt hook,
and in this way remove the membranes, and in doing this it may
become necessary to introduce the whole hand into the vagina; or
a wire blunt-hook, which will admirably answer the purpose, may
be made, by bending a piece of fine wire so as to form two parallel
strips nearly in contact with each other, the curved end of which
is to be again bent so as to form a hook; this may be introduced
into the the uterus, whenever hemorrhage is owing to retained
membranes, for the purpose of removing them. Other instru-
ments have likewise been recommended for this purpose, as Bond's
placental forceps, and Dewees' placental hook. But in the intro-
duction of the finger, or any of these instruments into the canal
of the cervix, no force must be employed, too much care and gen-
tleness ean not be observed; no attempts whatever should be made,
to effect dilatation, nor should these means be employed at all until
the cervical canal has become cylindrical and sufficiently open for
their free intromission. And as the development of the uterus
previous to the fifth month is not such as to warrant any fears of
a serious internal hemorrhage, the tampon may be used, in con-
junction with the other means, to check flooding, if circumstances
prevent the removal of the membranes. The introduction of the
tampon is sometimes attended with such disagreeable and painful
sensations that the patient can not endure its presence for even
ten minutes; in such cases, as well as in cases where it does not
check the hemorrhage, the evacuation of the uterine contents must
be promoted as soon as possible. It may be proper to remark
here, that when the hemorrhage is such as to threaten the life of

HEMORRHAGE AND ABORTION.

189

the mother, every means must be employed to arrest it, even
should the means effect the death and expulsion of the fetus, as
the safety of the mother alwajTs demands such sacrifice. When
the death of the fetus has occasioned the abortion the hemorrhage
is not generally excessive.

In the more advanced stage of pregnancy, when in consequence
of excessive hemorrhage or other cause it becomes necessary to
facilitate the expulsion of the fetus, the membranes may frequently
be ruptured with advantage, because at this period, the uterus has
increased in size sufficiently to receive two or three fingers, or even
the whole hand, should it become necessary to remove a retained
placenta. And the extraction of the placenta should always be
effected, when the abortion occurs at a period of utero-gestation,
in which the uterus will permit the introduction of the hand within
its cavity. Other means may likewise be employed to favor the
expulsion, as Blue Cohosh root, Black Cohosh root, infusion of
fresh Cotton bark, or Ergot, together with cold applications to the
pubes and hypogastrium, to aid in arresting the hemorrhage. At
this period I usually prefer as an internal hemostatic, the tincture
of Cinnamon, of which from half a fluidrachm to a fluidrachm
may be given every ten, thirty or sixty minutes, as the urgency of
the case requires, in a wine-glass of sweetened water; ten or fifteen
drops of Laudanum may be added to each dose, in case the pains
are very severe. After the embryo and its membranes have passed
away from the uterus, should hemorrhage still continue, it must be
treated in the same manner as recommended for flooding after
delivery at full term.

A weak solution of Sulphuric Acid has been frequently employed
in hemorrhages occurring during pregnancy, as well as after
delivery, with decided benefit. It is exhibited as a vaginal enema,
ten or fifteen drops of the acid being added to three or four ounces
of warm water. Care should be taken, however, not to employ it
when it is desired to check the abortion. Many persons use this
injection with the criminal intention of procuring an abortion.

In cases of hemorrhage occuring several days after the abortion
has apparently terminated, and which, as previously stated, are
owing to a retention of the placenta and membrane, the wire
blunt-hook may be slowly and carefully passed within the canal of
the cervix, and the membranes extracted by means of a gentle
manipulation ; if this can not be accomplished, the practitioner
will have to contend with the effects of putrefactive absorption.

190 AMERICAN ECLECTIC OBSTETRICS.

Putrefactive decomposition may be known by a fetid lochial dis-
charge, and absorption of the putrid matter gives rise to an irrita-
tive fever which may prove dangerous. The fever must be treated
upon general principles, being careful to support the strength of
the patient; and the uterus must be frequently syringed with a
tepid astringent infusion, as of Golden Seal and Geranium, for
the purpose of removing the putrified material as soon as it forms.
If the os uteri should be closed so as to prevent the introduction of
a canula for this purpose, the practitioner will have to limit his
attempts to mere vaginal injections, in which he may employ the
above astringent infusion or a dilute solution of Chloride of Soda-
In several cases of fever from putrefactive absorption, in which it
was impossible to syringe the uterus, as above advised, I have suc-
ceeded in preventing any serious consequences by administering,
in connection with the general treatment, an infusion of two parts
each of Blue Cohosh root and Unicorn root (Aletris far.), with one
part of Wild Indigo root. Infuse one ounce of the mixture in two
pints of water, and give a tablespoonful every two, or three hours,
or even oftener, if the symptoms are urgent. I prefer the infusion,
in these instances, to the concentrated preparations of the articles.
Peruvian bark in Port wine has also been used in a few cases with
apparent beuefit.

After an abortion, especially in advanced pregnancy, a bandage
should be applied around the abdomen, the same as after ordinary
labor, and the patient should be kept for several days in a state of
rest; if there be much exhaustion from loss of blood, the diet
must be similar to that recommended in uterine hemorrhage, or
flooding after labor at full term. A lochial discharge, as well as
secretion of milk is most commonly present, after abortion in the
advanced stage of gestation.

The sequelce, or after consequences of abortion, are irritative
fever, metritis, peritonitis, phlebitis, ulceration of the cervix,
anaemia, leucorrhea, menorrhagia, dysmenorrhea, organic disease
of the uterus, sterility, or phthisis.

When an abortion has once taken place, it is very liable to recur
during the following pregnancy, and to prevent the occurrence of
which, the practitioner should endeavor to ascertain its cause, and
remove it, if possible, by the appropriate treatment. Should it be
owing to tumors, diseased ovum, or other intra-uterine diseases,
treatment will be of little avail ; though in these cases the internal

HEMORRHAGE AND ABORTION.

191

use of alteratives, uterine tonics, proper diet, exercise, etc., may
be adopted with a faint hope that good may follow. If the uterus
be displaced, it must be restored to its normal position; should
ulceration of the cervix uteri be a cause, it must be treated by
applying locally Nitrate of Silver, solution of Sesquicarbonate of
Potassa, solution of Sulphate of Zinc, etc., the application to be
made by means of a speculum. The patient must likewise be
kept in a state of rest, and if treated during pregnancy, no vag-
inal injections must be used. Dysmenorrhea is frequently a cause
of abortion, and when present, the functions of the uterine system
must be attended to, administering uterine tonics, and pursuing
the means generally recommended in Eclectic teachings to remove
the difficulty ; and so in all other uterine derangements. If the
abortion is owing to a syphilitic taint of the system, this may be
remedied by the use of the officinal compound syrup of Stillingia,
which I am in the habit of preparing by adding to one pint of the
syrup, four drachms of the Iodide of Potassium and three
fluidrachms of the saturated tincture of Sheep Laurel (Kalnria
lat.) ; of this, the dose is one fluidrachm in half a gill of water, to
be repeated three or four times a day. The bowels must be kept
regular, the diet must be uutritious, avoiding fats and acids, the
surface of the body must be frequently bathed with a weak alka-
line solution, and too much exercise must be prohibited ; if the
male parent is contaminated with the disease, but little benefit can
be expected unless he is also placed under proper treatment. The
administration of mercury, so highly recommended by some
authors, is of no utility, as this agent will not only effect no cure
of the disease, but has a strong tendency to destroy the vitality
of the fetus, and thus add to the already existing cause of abortion.
Any other disease with which the patient may be affected, whether
general or local, must, if possible, be eradicated by the appropriate
remedies, which may be employed not only during the interval
between pregnancy, but likewise when this condition is present.

Anaemic or chlorotic patients should be treated with vegetable
and chalybeate tonics ; those who are plethoric, require light and
moderate diet, exercise, regularity of bowels, and depletion by
diuretics; and coition should be very moderate until pregnancy
occurs, during which it must be positively prohibited. If the
patient resides in a miasmatic district, usually so called, a removal
will in many instances be followed with benefit; if she be giving
suck when pregnancy occurs, the child must be weaned; if there

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AMERICAN ECLECTIC OBSTETRICS.

be any vesicle or rectal irritation, piles, or a constipated condition
of the bowels, these may be overcome by an attention to diet, aided
with laxatives, anodyne and mucilaginous enemata, quiet, and an
avoidance of all active medicines. As habitual abortions usually
occur at a regular period of pregnancy, the patient should at this
period be kept in the recumbent position, upon a hard mattress, in
a cool room, and be otherwise treated according to the peculiarities
or indications of her individual case; and which treatment should
be perseveringly pursued until the aborting period has passed by.

When habitual abortion obstinately resists our endeavors to
remove it, it will ultimately destroy the constitution of the patient;
and it therefore becomes necessary on her part to pursue a rigid
and self-denying course. The indications are, firstly, to avoid
pregnancy, until the functions of the reproductive organs have
been restored to a normal condition ; and secondly, to effect this
restoration. The only method by which the first indication can be
fulfilled is absolute and positive discontinuance of sexual inter-
course for a year or longer — or for such a length of time as may
be required to effect a healthy condition of the generative func-
tions. I am aware that various other means may be suggested, or
pursued to prevent pregnancy, but, in the cases under considera-
tion, it must be especially borne in mind, that not only is an
avoidance of this condition required, but it is imperatively
demanded that the sexual organs be maintained in a state of quiet,
entirely free from all excitement, and which can only be effected
by rigid abstinence.

The second indication is to be accomplished by bestowing a
careful attention toward both the uterine and general systems,
emplo}ring tonics, alteratives, and such other measures as may
from time to time be required. The tonics which I have found
more commonly beneficial are, the officinal compound wine of
Comfrey, the officinal compound syrup of Partridgeberry, or, a pill
composed of alcoholic extract of , Unicorn root, Caulophyllin, Sul-
phate of Quinia, and hydro-alcoholic extract of High Cranberry
bark, of each, equal parts; divide into pills of three grains each,
and administer three, four, or five daily, as may be necessary;
indeed, the vegetable uterine tonics, generally, may be employed
with advantage. The agents which I term uterine tonics, and
which are described in the Am. Dispensatory, appear to exert an
especial healthful influence upon the uterus, but of their peculiar
modus operandi, I am free to confess my ignorance. In connec-

HEMORRHAGE AND ABORTION.

193

tion with tonic remedies, alteratives will be found an important
part of the treatment. The compound syrup of Sarsaparilla, the
compound syrup of Stillingia, or other officinal syrup, either with
or without the addition of Iodide of Potassium, may be advan-
tageously employed ; but I have derived more benefit in these
cases from the following preparation, than from any other which
I have prescribed : Take of saturated tincture of Black Cohosh
root, fourteen fluidrachms ; tincture of Iodine, two fluidrachms :
mix. Of this tincture give fifteen drops in a fluidrachm or two
of water, three times a day; this may appear to be a small, or
not very active dose, yet its influence will be found prompt and
permanent.

In conjunction with this treatment, the bowels must be kept in
a soluble condition by the use of mild laxatives, so given as to
produce one, but not over two alvine evacuations, daily, approxi-
mating as nearly as possible to the natural healthy discharges;
and for this purpose I prefer the powder of Rhubarb and Bicar-
bonate of Potassa, heretofore referred to, under the treatment of
vomiting during pregnancy; this may be omitted, occasionally,
and cold or tepid enemata employed, as may be found to suit each
particular case. Active purgation is invariably to be prohibited,
except in plethoric patients, when it may be resorted to every
week or two, if not contra-indicated. Bathing the surface daily
with cold or tepid water, and once a week with a weak alkaline
solution, and drying with considerable friction, will materially
assist in the restoration to health, by bringing about a normal
condition of the skin, the functions of which will be found more
or less impaired in these cases ; the shower-bath has also been
advised, either of rain-water or salt-water, and where it is appli-
cable it will usually prove beneficial ; its temperature should range
between 75° and 85°, and the best time of using it, is upon rising
in the morning. Moderate exercise will be found indispensable,
and an avoidance of all indolent habits, as lying in bed late in the
morning, lying down after a meal to sleep, sleeping on feather-
beds, etc. The diet should be light but nutritious, using tender
fowls, meats, etc., but always avoiding fats and acids; and very
weak patients may use Port wine, Porter, or other suitable stimu-
lants, in moderate quantity during the dinner meal. Occasionally,
a change of air will prove serviceable. All bathing must be
omitted during menstruation. By a perseverance in this course
for one or even two years, the most obstinate cases of habitual

194

AMERICAN ECLECTIC OBSTETRICS.

abortion, when not owing to uterine adhesions, may be cured ;
and it may be proper to remark, that should pregnancy occur
shortly after dismissing the patient as cured, it is very necessary
that close attention be bestowed upon that condition, until five or
six weeks have passed beyond the previous aborting period, in
order to promote the certaint}r and permanency of the cure.

Before leaving this subject, I wish to refer to two things which
may occasion some trouble to the practitioner in the treatment of
abortion ; the first is, the difficulty in prevailing on some females
to keep quiet and confine themselves to the recumbent position for
a sufficient length of time. Not feeling any sickness, nor suffering
from any pain, the patient will be apt to treat the advice of her
physician, in this matter, very lightly, unless it is especially urged
upon her, explaining to her the consequences of a different course
of action, and the advantages attending its observance, among
which may be named the diminution of the tendency to abort, and
strong probability of its permanent cure, when the habit has been
overcome in any one pregnancy. The practitioner can not be too
particular in regard to this matter. The second point is relative
to the decided objections which are frequently made to vaginal
examinations. When a female, during an abortion, objects to an
examination of this kind, and the symptoms are not very urgent,
the physician will treat the case as well as circumstances will
permit ; but when the hemorrhage is great, and the serious conse-
quences that may happen from a persistence in the objection have
been explained, without effecting any change in the will of the
patient, it would be improper for the practitioner, as far as his own
reputation, alone is concerned, to assume the whole responsibility
of the case. He will, therefore, not manifest any irritation, nor
abruptly leave the patient, but will state to the friends, or the
patient, that the case has assumed a character which leads him to
desire council, and then, should any fatal result ensue from a con-
tinuance of such obstinacy, this course will free him from any
subsequent imputations, of neglect, malpractice, etc.

In a premature labor, the management will be the same as recom-
mended for labor at full term ; for as a general rule, during the
last three months of pregnancy, the hand may be introduced
within the uterus for the purpose of performing any manipulations
which may be required. But I would make one observation, that
if the hand of the practitioner be very large, and a manual opera-
tion is demanded during the seventh or eighth month, it will be

DEVELOPMENT OF THE HUMAN OVUM.

195

safer for the patient, and very humane on the part of the medical
attendant, to send for some medical friend, with a small hand.
This is a point too little heeded, and which, of itself, is frequently
a cause of grave results.

CHAPTER XX.

• DEVELOPMENT OF THE HUMAN OVUM.

The changes undergone by the uterus, during pregnancy, have
already been referred to; and it will now be proper to notice those
changes which occur, during pregnancy, in the ovum, as it pro-
gresses in its development. Shortly after conception, a layer of
coagnlable lymph liues the whole internal surface of the uterus,
which is at first of a soft, gelatinous nature, but which soon
becomes imperfectly organized, vascular, and of a reddish color ; it
is called the membrana caduca (caducous membrane), or membrana
decidua (deciduous membrane). Several other names have been
applied to it, as epichorion by Chaussier, epione by Dutrochet,
perione by Breschet, anhistous membrane by Velpeau, adventitious
lamina by de Blainville, etc., etc. This membrane is about one
line in thickness, and is in contact with the whole of the inner
uterine surface; its inner, or fetal surface is smooth and polished,
with strise and depressions which lead into canals, bearing some
resemblance to that of serous membranes, and its external or
uterine surface is rough and unequal, and closely adheres to the
internal surface of the uterus. It is not persistent in its character,
as it is formed only during conception, and is expelled with the
ovum and its membranes whenever this occurs. Within this mem-
brane is a space or cavity called the cavity of the decidua, which is
filled with a limpid, serous fluid, to which M. Breschet has given
the name hydroperion. This fluid is present simultaneously with
the caducous membrane, increases in quantity as the uterus
enlarges, and continues to be secreted, according to Breschet, until
the caduca vera and caduca reflexa come in contact with each
other, or toward the fourth month ; it is supposed that this liquid
affords nourishment to the embryo during the early months,
before a direct placental communication is established between it
and its mother.

196

AMERICAN ECLECTIC OBSTETRICS.

Fig. 28. The manner by whieh the ovum becomes

enveloped in this membrane is supposed to be
as follows: having passed through the Fal-
opian tube, until it arrives at its uterine orifice,
t pushes before it a portion of the membrana
caduca, until the whole ovum is surrounded
and inclosed by this membrane (f, Wig. 28).
The portion of membrane thus covering the
ovum, is called the decidua ovuli, or reflexa
(ovuline, or reflected decidua), while that in
contact with the uterine walls, is termed the
decidua uteri, or vera (uterine, or true decidua).
The Caduca, after the ovum grows, the decidua reflexa ap-

THE ARRIVAL OF THE OVUM oacheg ^ ^ ^ deddua

into the Uterus. a . . . . . , ,. . . ,

a. The cavity of the uterine vera, the cavity of the decidua diminishes,

Neck- until, finally, at the third month the cavity is

BB. Uterine Orifices of the Fal- . , , ' , a - i . .

lopian Tubes. obliterated, and the two decidua, coming in

c. External, or uterine Ca- coritact become agglutinated into one mem-

duca. ' <-D<=l

d. cavity of the Decidua. brane. The ovum, it will be seen, is not corn-
EE. Angles at which the De- ltl surrounded bv the decidua reflexa, and

cidua vera is reflected t J «- 7

by the advance of the at that part of the uterus from which this
membrane was detached by the advancing
ovum, the surface is lined by no membrane
whatever. At this uncovered point a new structure is developed
between it and the ovum, bearing some resemblance to the mem-
brana decidua, and which is called decidua serotina, and here the
subsequent formation of the placenta takes place. The uses of the
membrana caduca, are, according to Moreau, " to prevent the ovum
from floating loosely in the cavity of the uterus ; to maintain it
in contact with a fixed point of the parietes of this organ, until it
has contracted sufficiently numerous and firm attachments to
enable the embryo, after being developed during the first stages of
pregnancy at the expense of the surrounding fluids, to extract from
the blood of the mother, the materials suitable for its nutrition and
subsequent growth ; to determine the place of insertion, form, and
extent of the placenta ; to prevent superfetation ; and, according
to Lobstein, to transmit to the chorion and amnion the vessels
which furnish these membranes with the elements of nutrition
and exhalation."

The above is the description generally given by authors relative
to the caducous membrane; still, it is not a settled question, and

Ovum

F. Chorion.

G. Amnios.

DEVELOPMENT OF THE HUMAN OVUM.

197

much diversity of opinion prevails in regard to it. Some consider
it to be a secretion, or exhalation from the internal mucous coat
of the uterus, effected by the peculiar excitement resulting from
conception; while others view it as an exfoliation of this mucous
coat, itself, which, from a similar cause, has undergone considerable
changes in its consistence and vascularity. The former is the most
commonly received opinion, and, probably, the most correct one ; it
maintains, that the excitement caused by a fruitful coition occasions
the secretion of a plastic lymph, which coagulates and forms a
kind of false membrane or caduca, analogous to those produced on
inflamed surfaces by the exhalation and coagulation of an albumi-
nous fluid, and which is entirely distinct from the mucous mem-
brane, although it adheres, more or less firmly, to the latter by
numerous vascular villi, or prolongations, which frequently extend
into the canal of the cervix, or Fallopian tubes. When the adhe-
sion of this false membrane is but slight, the ovum, upon entering
the uterine cavity, instead of pushing forward a decidua reflexa at
the orifice of the tube, may slip between the caduca and uterus,
and form an attachment at some otber point, thus giving rise to
the various placental insertions which are met with in practice.

The opposite opinion maintains that the utricular glands of the
uterus become elongated, augmented in size, and contorted, their
secretion increases, the vessels of the mucous membrane become
more fully developed in size and number, and a substance com-
posed of nucleated cells fills up the interfollicular spaces in which
the bloodvessels are contained. These changes produce a thicken-
ing and softening of the mucous membrane itself, with increased
vascularity, thus forming the deciduous membrane. But, as Prof.
Meigs observes, " I can not readily comprehend how, after all this
structure is once thrown oft' as a decidua, it can ever be reproduced
for the service of subsequent pregnancies." Dr. Carpenter inquires,
if the views relative to the mucous membrane of the uterus being
the decidua, are well-founded, how are we to explain the forma-
tion of the decidua continuously over the upper orifice of the cer-
vix uteri, and over the orifices of the Fallopian tubes, as is fre-
quently, though not always, the case ?

Again, it has been asserted by Dr. Lee, that this membrane is not
formed unless the ovum reaches the uterus, but in this he is evi-
dently in error, as there are, at least to my mind, a sufficient num-
ber of facts recorded to prove its presence independent of the
arrival of the ovum at the uterus. And, if I am not mistaken, Prof.

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AMERICAN ECLECTIC OBSTETRICS.

Meigs, as well as other investigators, have observed the decidua in
cases of extra-uterine pregnancy. Moreau states, that " it is even
found in cases of tubular and ovarian pregnancy, provided the
pregnancy be not too far advanced, and have not exceeded five or
six months, for we are inclined to believe that it disappears at a
later period." Velpeau denies that the membrane is organized,
hence, he has called it anhistous ; but there are sufficient proofs of
its organization, as, for instance, its vascularity ; it has also been
injected by Ruysch, Burns, Lobstein, and others — beside, it is liable
to disease, and toward the last becomes very thin, like serous or
cellular tissue.

Hunter asserted that the deciduous membrane had three open-
ings, one at the inner orifice of the cervix, and one at each orifice
of the Fallopian tubes ; were this the case, no decidua reflexa would
be formed, but the ovum in entering the uterus, would at once
pass through the opening into the cavity of the decidua, from
whence it could escape out of the uterus through the opening at the
inner orifice of the cervix, and no conception would result. Such
openings in the membrane may occasionally be present, but accord-
ing to the investigations of many excellent observers they do not
occur as a general rule. It has also been denied that the decidua
reflexa is a mere reflected portion of the decidua vera, as the tex-
ture of the two are said to be non-identical ; and that the reflexa is
probably formed by the agency of nucleated cells from the plastic
materials thrown out from the decidua vera, in the same manner as
the chorion is supposed to be formed in the Fallopian tube, from
similar materials secreted from its lining membrane.

From this brief review of the subject, it will be seen that it is
still involved in obscurity, and those who desire further informa-
tion regarding it, are referred to the various essays by Hunter, Lee,
Chaussier, Breschet, Velpeau, Carus, Granville, M. Coste, Weber,
Sharpey, etc.

At the period of full development of the ovule, it escapes from
the vesicle inclosing it, and passes into the Fallopian tube through
the agency of the fimbriated extremity of this organ, gradually
traversing its canal until it arrives at the uterine cavity. The
modifications undergone by the human ovule in its passage through
the Fallopian tube, are unkuown, but are supposed to be similar to
those which occur in the eggs of mammiferous animals, particu-
larly those of the rabbit and dog. In these animals, the first
change which has been observed in the ovule after its escape from

DEVELOPMENT OF THE HUMAN OVUM. 199

the ovary, is the entire disappearance of both the germinal vesicle
and germinal spot, while at the same time there will be found a
collection of granules in the central portion of the ovum. During
its travel through the first half of the oviduct, the vitelline mem-
brane becomes somewhat thickened, while a layer of the granula-
tions which formed the proligerous disk of the ovule previous to
its departure from the ovary, surrounds the ovum, but which dis-
appears as it traverses the second half of the oviduct, having a
layer of a transparent, gelatinous substance to occupy its place
around the vitelline membrane, and which albuminous layer, as
well as the thickening of the vitelline membrane, continues to
increase. While these changes are being effected, the yelk grad-
ually increases in density, forming a compact, homogeneous mass —
a transparent fluid occupying the space existing between it and the
interior surface of the vitelline membrane; finally, the yelk sep-
arates into two regular spherical divisions ; these again separate,
forming four spheres, and this separation continues, until from the
numerous small spherical divisions which are thereby formed, the
yelk presents a mulberry or raspberry appearance. These spheres
or granulations decompose as the ovum advances toward the cavity
of the uterus, and finally disappear, being replaced by a clear and
transparent fluid. They are supposed to condense on the inner
wall of the vesicle, forming there a second vesicle which has been
called the blastodermic vesicle or membrane, or germinal membrane or
area. As this blastoderm becomes developed after the arrival of
the ovum in the uterus, the albuminous layer surrounding the
vitelline membrane disappears, while this membrane diminishes in
thickness. About the sixteenth or seventeenth day will be observed
a rounded, whitish spot, at some point of the blastodermic vesicle,
standing out apparently detached, and which is named the embry-
onic spot, or tache embryonnaire; it is composed, the same as the
blastoderm, of cellular granulations, and from it commences the
gradual development of the embryo. The blastoderm is composed
of two laminae, the external or serous layer, and the internal, mucous,
or vegetative layer, the former of which is supposed to give origin
to the brain and spinal cord, organs of sense, cartilage, bones, skin
and muscles, and the latter to the lungs, liver, spleen, and digestive
tube. A third layer has also been recognized by some investigators,
which is situated between the two just named ; it is called the mid-
dle or vascular layer, and is supposed to assist in the development
of the heart, circulatory apparatus, etc. The time required for

200

AMERICAN ECLECTIC OBSTETRICS.

the passage of the human ovum from the ovary to the uterus is
supposed to be from eight to ten or twelve days, and it is about
this latter period, the twelfth day of pregnancy, that we can dis-
tinctly observe the embryo, which then appears to be a mere
amorphous vesicle, measuring about three lines, while the entire
ovum measures six or seven lines. The envelopes of the ovum are
three, the Chorion, Tunica Media, or Middle Membrane, and the
Amnion ; and its accessories are four, the Umbilical Vesicle, the
Allantois, the Placenta, and the Umbilical Cord.

The CHORION is a thin, glistening, transparent membrane,
very analogous to serous tissues, quite resisting for its tenuity, and
forms the external covering of the ovum, passing also over the
fetal surface of the placenta and the external face of the umbilical
cord, and may be considered as corresponding to the internal lining
membrane of an eggshell. It is formed by the union of the
vitelline membrane with the albuminous envelope which this
acquires while in the oviduct ; however, this is still a question
among physiologists, some of whom suppose it to be formed by the
external layer of the blastodermic vesicle and the allantois. It has
two surfaces, an inner or fetal surface, and an external or uterine
surface. Both of these surfaces are smooth at first, but at an
early period, about the second week of pregnancy, the external
surface presents minute granulations, which rapidly augment in
length, forming numerous villi or velvety prolongations with
which the chorion soon becomes covered. These spongy, cylin-
drical villi disappear from the general surface about the second
month, but at the spot where the chorion comes in contact with
the uterus, and where the secondary caduca or decidua serotina is
formed, they enlarge and become vascular, giving origin to the
placenta. The vascularity of the chorion does not manifest itself
until after the development of the allantois, when it consists of
two layers or laminae, the external or primitive one of which is non-
vascular, and is called the exochorion; while the other, the internal
or allantoid layer, is highly vascular, and is named endochorion.
In the early period of pregnancy the chorion is separated from
the amnion by an albuminous layer, which condenses into a thin
web-like membrane termed tunica media; and this albuminous
fluid is more abundant in the first weeks of gestation. Iu the
midst of this fluid is situated the umbilical vesicle. As the ovum
matures, the external face of the chorion unites with the decidua

DEVELOPMENT OP THE HUMAN OVUM.

201

reflexa, while its inner face comes in contact with the amnion after
the second month ; there have been instances, however, where at
full term, a considerable quantity of fluid existed between the
amnion and chorion, termed false waters; its escape has given rise
to the belief that the liquor amnii had passed off. When this
fluid is discharged several times during one pregnancy, it consti-
tutes hydrorrhea (see page 164). The chorion serves to envelope
and protect the ovum during its passage from the oviduct to the
uterus, furnishes a sheath for the umbilical cord, assists in the
production of the placenta, and, probably through the attachment
of its villi to the decidua, nourishment is absorbed from the
maternal blood by which the vitality of the embryo is sustained ;
at the parturient period it assists, in connection with the amnion,
to form a bag containing the amniotic liquor, which materially
promotes the softening and dilatation of the os uteri.

The AMNION is the most internal covering of the ovum, around
which it forms a sac; it is very thin, smooth, and transparent, and
is more dense and resisting than the chorion, which it very much
resembles in structure and appearance. It is supposed to be
formed by the internal lamina of the fold of the external serous
layer of the blastoderm around the embryo (which forms the
cephalic and caudal hoods), and is continuous with the margins of
the ventral opening of the embryo ; however, there are several
other views concerning its origin. Its internal surface exhales a
liquid in which the embryo floats freely ; its external surface is
more or less separated from the chorion, the space between them
being filled with an albuminous liquid. It apparently consists of
condensed cellular tissue, in which neither bloodvessels nor nerves
have yet been recognized. As the development of the ovum pro-
gresses, the space between the amnion and chorion diminishes, the
albuminous fluid found between them gradually disappears, until
finally the two envelopes come in contact and adhere to each other.
The amnion forms the outer coat of the fetal face of the placenta,
and of the cord ; and a division of the cord shows us the chorion
placed between the cord proper and the amnion. Its uses are to
furnish the liquor amnii, to aid in forming the membranes, and
bag of waters, and to serve as a covering to the umbilical cord, the
liquor amnii, and the fetus.

The LIQUOR AMNII, also known as the amniotic fluid, waters
of the amnios, etc., is a fluid contained within the amnion, and in
14

202

AMERICAN ECLECTIC OBSTETRICS.

which the embryo floats ; by some it is supposed to be an exhala-
tion or secretion from the amnion, by others to be a product of the
fetus, and by others again to be a secretion from both the fetus
and its parent. The probability is, that the liquor amnii proper is
exhaled by the internal surface of the membranes of the ovum, the
elements of which are furnished by the uterine vessels, and that it
may be mixed or adulterated with the fetal excretions, especially at
an advanced period of pregnancy. This fluid varies in quantity
as well as in its properties; during the early stage of gestation,
when compared with the fetus, it is proportionally greater, there
being from half a fluidrachm to a fluidrachm present when the
embryo can hardly be seen by the naked eye, and although it con-
tinues to increase until full term, yet its relative proportion to the
size of the fetus gradually diminishes, so that at parturition, while
the fetus may weigh from six to eight pounds, the quantity of fluid
will seldom be found to exceed a pint. In some few cases it may
amount to quarts. Its appearance varies from that of a transparent
and limpid fluid, more commonly observed in the early period of
pregnancy, to that of a thick, slightly yellow, green, or brown color,
and which is more usual to the advanced stage. It is soft and
viscous to the touch, has a specific gravity of 1.004, and emits an
odor somewhat resembling that of semen, though occasionally,
especially when the fetus is dead, this odor is putrid and very
offensive ; its taste is saltish. Sometimes it becomes milky, or
clouded, and frequently contains white clots, which are detached
pieces of the fetal sebaceous covering ; greenish or dark-colored
flakes, being portions of undiluted meconium, are likewise often
observed in it. Its most common appearance at parturition is that
of a dingy liquid, having a tinge of yellow or green. Heat renders
it cloudy ; alcohol or caustic Potassa causes a fleecy precipitate,
with which nutgalls form a brownish deposit, similar to a dilute
solution of gelatin ; Nitrate of Silver occasions an abundant white
precipitate, which is insoluble in Nitric Acid; and the tincture of
Violets becomes changed to green by it. Analysis has found in it
a large proportion of water, with albumen, albuminate of soda,
chloride of sodium, carbonate of soda, phosphate and carbonate of
lime, urea, and, probably, a peculiar free acid, called amnio or
amniotic acid. Its use appears to be to protect the embryo from
any severe compression of the uterine walls; to protect it from
the effects of falls or blows; to prevent any adhesion of the fetus
while in utero, and allow it free motion; to protect the fetus,

DEVELOPMENT OF THE HUMAN OVUM. 203

during parturition, from the injurious effects of uterine contrac-
tion upon its body, until all its parts are in a suitable condition to
permit its expulsion ; to aid in the dilatation of the os uteri, at term,
by means of the bag of waters, as well as to lubricate the parts
through which the fetus has to pass, thereby facilitating its
delivery. Some physiologists believe that it likewise aids in nour-
ishing the fetus, previous to the formation of the placenta and
establishment of the fetal circulation.

The UMBILICAL VESICLE, vesicula umbilicus, or vesicula
alba, is formed by the internal, or mucous layer of the blastoderm ;
it is of a rounded, or pyriform shape, is situated in the space
between the amnion and chorion, and communicates by a long
pedicle, or duct, with the intestinal tube, upon which it lies. It
forms a sac, seldom larger than a small pea, and contains a viscid,
transparent, yellowish-white fluid, in which may be seen a few
globules, and numerous granules. It appears to be composed of an
external or vascular layer, and an internal or mucous layer. The
following account of its formation, is given by Prof. Meigs : " When
the blastoderm has partly undergone the morphological changes
that convert it into the earliest rudimental embryon, part of the
yelk corpuscles still remained unappropriated; and as they are
still contained in their original vitelline membrane, they constitute
a small, but visible ball, called the umbilical vesicle. Originally,
the vitellus was a sphere, of which Fig. 29, represents a segment.
The blastoderm is developed upon a segment FlG 2g

of this sphere as at a, in Fig. 30. When the
blastoderm doubles or folds its edges inward,
it pinches (or contracts), a portion of the vitel-
lary ball, as in Fig. 31. In a still further pro-
gress, as shown by Fig. 32, the portion of the
vitellary ball that remains outside of the em-
bryon is connected to the embryo by a deli-
cate tube, or vitellary duct." Velpeau states,
that this duct opens into the fetal ilium; Rigby,
Ludlow, and Oker, consider the appendicula Segment of the Spher*
vermiformis as the remains of it. As preg- 0F THE VlTELLUS-
nancy advances, the umbilical vesicle becomes atrophied, and the
development of the amnion removes it further and further from
the embryo, at the same time elongating its duct or pedicle, the
canal of which remains open till the sixth, or eighth week of

204

AMLlICAN ECLECTIC OBSTETRICS.

Fig. 30.

Blastoderm developed upon
the Segment of the Sphere

OF THE VlTELLUS.

gestation, after which it is obliterated,
and the umbilical vesicle becomes flat-
tened, diminished, of a lenticular shape
and gradualty fused into the cord, and en-
tirely disappears after the third or fourth
month ; in a few rare cases, it has been
found at full term. It use is supposed to be
to afford nourishment to the embryo, until
its placental connection with the mother
is established.

The external or vascular layer, of the
umbilical vesicle has ramifying over its
parietes two bloodvessels, an artery and a
vein, which are called the omphalo-mesenteric, or vitello mesenteric
vessels, and which accompany the pedicle, forming a part of it. The
Fig. 31. omphalo-mesenteric artery arises from the

aorta, and as it reaches the summit of
the intestinal convolutions, it gives off
branches to the mesentery and to the in-
testine ; then it extends to the pedicle,
through which it passes until it reaches
the umbilical vesicle, upon which it is
distributed. In the adult, that part which
supplies the mesentery is converted into
Inward Folding of the Edges a mesenteric artery, all the rest being oblit-
of the Blastoderm. erated, as the umbilical vesicle disappears.
The omphalo-mesenteric vein, enters the abdomen, passes around the
duodenum, and opens into the umoilical vein just as this is emer-
ging from the liver. In its
passage around the duode-
num it gives off' branches to
the stomach and intestines,
and when it empties into the
umbilical vein, it sends a
large trunk to the liver; the
whole disappears with the
vesicle and its pedicle, ex-
cept that portion which fur-
Fcrther Progress of the Blastoderm. nishes the above branches,
which remains in the adult as the ventral, or hepatic -portal vein.
Prof. Meigs admirably illustrates the arrangement of the omphalo-

Fig. 32.

DEVELOPMENT OF THE HUMAN OVUM.

205

mesenteric vessels and cord, Fig 33.

by- the following diagram,
Fig. 33 : "Let a a, be a por-
tion of the abdomen of the
embryo, and c c, the navel,
or umbilical ring; b b, the
navel string, or cord, laid
open; d, the umbilical vein,
bringing back the blood from
the placenta, and passing into
the belly at the ring, to go to
the liver; e, f, the two um-
bilical arteries of the fetus;
n, the umbilical vesicle, or
vitelline sac, whose pipe, con-
duit, or efferent-duct runs
along the umbilical cord to
the navel, and passing into
the belly empties itself into
the ilium, G G, which bends up Diagram of the Omphalo-mesenteuu: Vessels
to receive the discharge ; k, l, represents the omphalo-mesenteric
vessels."

The ALLANTOIS, or allantoid vesicle, is a small sac, or bladder,
which may be observed about the tenth day, and which arises from
the inferior part of the intestinal canal, or caudal extremity of
the embryo ; it is found near the umbilical vesicle, between the
chorion and amnion: its growth is rapid, and soon becomes
attached, .by its base, to the inner surface of the chorion. On the
parietes of the allantois are distributed the terminal branches of
the two umbilical arteries and vein. The urachus, or pedicle of the
allantois, is a cord, which is pervious in early embryonic life, and
which passes out of the fetal body at the navel, being accompanied
by the umbilical bloodvessels to the chorion, which they pierce,
sending branches into its villi, which increase in size as these villi
form the placental connection with the uterus.

The allantois rapidly disappears, so that in a few days after its
appearance there can be observed only a cord of greater or less
length, passing from the embryo to the chorion, and containing
the umbilical vessels within it; this cord, likewise, gradually
becomes lost in the substance of the umbilical cord, only a portion

206

AMERICAN ECLECTIC OBSTETRICS.

of it remaining within the abdomen of the embryo, to form
the urachus, at the rectal termination of which is subsequently
formed the urinary bladder. In consequence of this early disap-
pearance of the allantois, many physiologists have denied its exist-
ence. The use of this vesicle, or membrane, is to conduct blood
from the embryo to the chorion, or, as remarked by Prof. Meigs,
" the allantois may be said to be a bladder, or vesicle, upon which
the umbilical arteries climb toward the wall of the womb, to
attach themselves there." It is, likewise, stated to receive the urine
of the fetus, secreted in early uterine life. Dr. Carpenter makes
the following remarks in relation to this vesicle :

" With the evolution of a circulatory apparatus, adapted to
absorb nourishment from the store prepared for the use of the
embryo, and to convey it to its different tissues, it becomes neces-
sary that a respiratory apparatus should also be provided for
unloading the blood of the carbonic acid, with which it becomes
charged during the course of its circulation. The temporary respira-
tory apparatus, now to be described, bears a strong resemblance in its
own character, and especially in its vascular connections, with the
gills of the mollusca; which are prolongations of the external sur-
face (usually near the termination of the intestinal canal), and
which almost invariably receive their vessels from that part of the
system. This apparatus is termed the allantois. It consists at
first of a kind of diverticulum, or prolongation, of the lower part
of the digestive cavity, the formation of which has been already
described. This is at first seen as a single vesicle, of no great
size; and in the fetus of mammalia, which is soon provided with
other means of aerating its blood, it seldom attains any considera-
ble dimensions. In birds, however, it becomes so large as to
extend itself around the whole yelk-sac, intervening between it
and the membrane of the shell ; and through the latter it comes
into relation with the external air. The diagram (Fig. 34), will
serve to explain its origin and position in the human ovum. The
chief office of the allantois, in mammalia, is to convey the vessels
of the embryo to the chorion ; and its extent bears a pretty close
correspondence with the extent of surface, through which the
chorion comes into vascular connection with the decidua. Thus,
in the carnivora, whose placenta extends like a band around the
whole ovum, the allantois also lines the whole inner surface of the
chorion, except where the umbilical vesicle comes in contact with
it. On the other hand, in man and the quadrumana, whose pla-

DEVELOPMENT OF THE HUMAN OVUM.

207

centais restricted to one spot, the allantois is small, and conveys
the fetal vessels to one portion only of the chorion. When these
vessels have reached the chorion, they ramify in its substance, and
send filaments into its villi ; and in proportion as these villi form

Fig. 34.

Diagram of the Human Ovum at the time of the Formation
of the Placenta.

A. Muco-gelatinous substance blocking up the Os Uteri,
B B. Fallopian Tubes.

C C. Decidua Vera, at 2 C, prolonged into the Fallopian Tube.

D. Cavity of the Uterus, almost completely occupied by the Ovum.

E E. Angles at which the Decidua Vera is reflected.

F. Decidua Serotina.

G. Allantois.

H. Umbilical Vesicle.

I. Amnios.

K. Chorion, with the outer fold of Serous Tunic.

that connection with the uterine structure, which has been already
described, do the vessels increase in size. They then pass directly
from the fetus to the chorion, and the allantois being no longer of
any use, shrivels up, and remains as a minute vesicle, only to be

l

208

AMERICAN ECLECTIC OBSTETRICS.

detected by careful examination. The same thing happens in
regard to the umbilical vesicle, from which the entire contents
have been by this time exhausted ; and from henceforth the fetus
is entirely dependent for the materials of its growth, upon the sup-
ply it receives through the placenta, which is conducted to it by
the vessels of the umbilical cord. This state of things is repre-
sented in the diagram {Fig. 34). The allantois has a correspond-
ence in situation with the urinary bladder; but it is only the lower
part of it pinched off, as it were, from the rest, that remains as
such. The duct by which it is connected with the abdomen grad-
ually shrivels ; and a vestige of this is permanent, forming the
urachus, or suspensory ligament of the bladder, by which it is con-
nected with the umbilicus. Before this takes place, however, the
allantois is the receptacle for the secretion of the corpora ivolffiana,
and of the true kidneys, when they are formed."

The PLACENTA or afterbirth is a soft, spongy, vascular mass,
occupying about one-third of the external covering of the ovum,
and forming the principal connection between tbe embryo and the
uterus. It is a flattened, irregularly circular body, of a more or
less intense reddish-gray color, varying in diameter from six to
nine inches, sometimes having one diameter longer than the others^
about an inch in thickness at its point of junction with the umbil-
ical cord, from which it gradually tapers off toward the circum-
ference, which seldom exceeds two or three lines, and weighing
one or two pounds, depending, however, upon its size and the
amount of blood it contains. It most usually has the umbilical
cord inserted at its center; occasionally this passes into it, at or
near the circumference, and with this disposition the vessels of the
cord will frequently be found to separate into numerous branches
before they reach the substance of the placenta; this is termed the
battledore placenta. The placenta, umbilical cord, and membranes,
are collectively called the secundines.

The placenta presents two surfaces, an external or uterine, and an
internal or fetal. The fetal surface has a smooth, polishecf appear-
ance, and is marked by the numerous radiations of the vessels of
the umbilical cord, forming a kind of network, which may enable
us to distinguish the placenta in artificial deliveries ; this surface
is covered by the chorion and amnion, the former of which inti-
mately adheres to it, and sends processes between the lobules,
while the latter is loose and nearest the fetus. The uterine surface,

DEVELOPMENT OF THE HUMAN OVUM. 209

when removed from the uterine wall, presents a uniform, but not
smooth appearance, and is slightly convex; it has a fleshy
resemblance, and is divided by deep sulci or furrows into numerous
irregularly shaped lobes, which are connected with each other, at
the bottom of these sulci, by a loose cellular, or, according to
Velpeau, lamellated, albuminous tissue, which is easily lacerated.
Upon an investigation, it will be found that each of these lobes or
cotyledons, is formed by the ramifications of one branch of the
umbilical arteries and veins, on their first separation, and that the
vessels of one lobe do not anastomose with those of another, and
but slightly with each other. This surface is not in direct contact
with the uterine wall, but is separated from it by the interposition
of the decidua serotina, an albuminous layer analagous in appear-
ance to the true caducous membrane, which is more firmly
attached to the placenta than to the uterus, and which enters into
the fissures separating the lobes, when not too deep, in which latter
case it passes from one lobe to another, forming a kind of mem-
branous bridge, while a thick partition of cellulo-mucous substance
penetrates deeply between the lobes. The circumference of the
placenta is thin and irregular, and measures from twenty-one to
twenty-seven inches; its margin is continuous with the chorion,
and is contiguous to the fold formed by the caduca when passing
over the ovum to constitute the decidua reflexa ; between this fold
and the placental circumference, is a thickening or density of sub-
stance, so disposed for the reception of the placental border as to
form a triangular sinus.

The earliest rudiments of the placenta are observed toward the
termination of the first month of pregnancy, which become gradu-
ally developed until the third month, when the organ acquires its
proper character, and continues to increase in size with the growth
of the fetus. As soon as the ovule has reached the uterus, the
chorion is observed to be covered with numerous villi which give
to it a downy appearance, but those villi in contact with the
decidua reflexa, probably from an absence of proper material for
their development, become atrophied and filamentous, serving
merely as points of union between the chorion and decidua ; while
those which are exposed to the uterine wall, receiving nourishment
from the exudation of lymph which takes place on the surfaces of
both the uterus and ovum, continue to develop themselves, elon-
gate, become converted into vessels, and ultimately form the
placental part of the placenta. {Fig. 34.) The uterine portion of

210

AMERICAN ECLECTIC OBSTETRICS.

the placenta is the lymph above referred to, which forms a thin,
delicate tissue known as the decidua serotina, and which is fur-
nished more copiously by the uterus, on account of the superior
size and vitality of this organ compared with those of the ovum.
At that portion of the uterus where the placenta is situated, will
be found large cells or sinuses which communicate freely with each
other, but which do not extend beyond the decidua serotina, this
membrane answering the purpose of a valve to prevent the blood
in them from passing into the cavity of the gravid uterus ; these
cells are the uterine sinuses, and into them the blood is poured by
the curling uterine arteries terminating in a capillary extremity.
The capillary vessels of the fetus, covered by the thin decidua,
insinuate themselves into these sinuses, and, without any inter-
ference of the circulation of either the fetal or maternal fluid, the
change is here effected which probably removes the effete matter
of the fetal blood, while at the same time this fluid absorbs oxygen
from the maternal blood; and these changes are brought about
without the existence of any vascular intercommunication between
the mother and fetus, the action somewhat resembling that which
takes place in the lungs of an adult, between the venous blood and
the atmospheric air. The placenta may attach itself to any part of
the internal surface of the uterus, more commonly at or near the
orifice of one of the tubes, occasionally in the vicinity toward the
fundus, rarely toward the neck, and still more seldom over the
inner os uteri; this latter position is termed placenta previa, and
is dangerous to both mother and child on account of the hemor-
rhage which is apt to ensue as it becomes detached from the uterine
wall, during labor, by the dilatation of the os uteri. These placental
situations are supposed to be determined by the character of the
adhesion existing between the caduca and uterine wall, as to firm-
ness as well as to the degree of resistance afforded by the caduca
to the advancing ovule ; thus, if the adhesion be weak between the
decidua and uterine wall at the utero-tubal orifice, the ovule may
slip or pass down between them until it meets with sufficient
resistance to impede its further progress, and at this point, where
it is stayed, commences the formation of the decidua reflexa, as
well as of the placenta. And if the attachment be so slight as to
permit the fecundated ovule to pass out of the uterus and through
the canal of the cervix, conception does not take place. It must be
borne in mind, that the attachment of the placenta is by apposition
only, the decidua serotina being interposed between it and the

DEVELOPMENT OF THE HUMAN OVUM.

211

uterine wall ; and when actual adhesion occurs, it is invariably the
result of disease.

In cases where more than one fetus is present, we generally
find a separate cord, placenta, and set of membranes for each one,
and though the placentae may be joined together, forming appar-
ently a single organ, yet there will be no anastomosing of the
bloodvessels, the circulation of each child being perfectly indepen-
dent, so that should one die or become diseased in utero, the other
may continue to live or be healthy. In some few instances, there
have been found exceptions to this — two children have been
inclosed in one bag of membranes, or when in separate ones, there
has been a communication of their vascular systems. The use of
the placenta is to form the principal connestion between the
embryo and the uterus in order to contribute to the nourishment
of the former. {Fig. 34.)

The UMBILICAL CORD, funis umbiliealis, or navel string, is a
long, flexible, and vascular cord which serves as a connecting
medium between the fetus and placenta. It has two insertions, a
placental and a fetal. The placental insertion is usually in the
center of the placenta, though it may occur at any point between
the center and circumference of this organ ; the fetal insertion is
at the umbilicus. At birth, its average length is from sixteen to
twenty-four inches, though it frequently varies from this measure-
ment, having been found several feet long, and again only six or
seven inches. Its thickness is likewise variable ; ordinarily it is
about equal to that of the little finger ; when it exceeds this it is
termed a fat cord, and when it is smaller it is called a lean cord.
This variation in its thickness depends upon the larger or smaller
amount of a viscid, semi-transparent fluid which is infiltrated in
the cellular tissue of the cord, and which is named the gelatine of
Wharton; this fluid is coagulable by heat and acids, and when
unequally distributed occasions swellings or nodes on the cord.

During the early weeks of pregnancy the umbilical cord does
not exist ; its first appearance is about the end of the first month,
when the embryo is fully separated from the blastodermic vesicle,
at which period it is composed of the duct of the umbilical vesicle,
urachus, omphalo-mesenteric vessels, and a covering of amnion
and chorion. It is now cylindrical, thick and short, but elongates
in proportion as the umbilical vessel removes and disappears. At
about the commencement of the tnird month, the umbilical vesicle,

212

AMERICAN ECLECTIC OBSTETRICS.

urachus, and omphalo-mesenteric vessels being obliterated and
amalgamated with the cord ; this now consists of two arteries, one
vein, fine areojar tissue, gelatine of "Wharton, and an external
covering of amnion and chorion, which elements remain until the
termination of pregnancy. At first the cord is straight, but after
the second month, a torsion of the vessels commences, the two
arteries run uniformly and spirally around the vein, usually in a
direction from left to right ; the vein thus occupying the axis of
the cord.

The vein of the umbilical cord is of a thickness nearly, if not
quite equal, to that of the two arteries combined ; it has no
valves, its walls are thin but firm, and it performs the functions
of an artery, carrying the pure and vitalized blood from the
placenta to the fetus. It arises from the placenta ; the venous
ramifications of each placental lobe uniting on the surface of the
placenta to form the cord, which passes onward into the umbilical
ring of the fetus, where it separates from the two arteries and pro-
ceeds toward the liver.

The two arteries of the umbilical cord arise from the fetal
internal iliacs, of which they are branches, and proceed toward the
umbilicus, where they separate and traverse the vein in a tortuous
manner until they reach the placenta, into which they give off"
numerous ramifications. The walls of the arteries are thick,
resisting, and contractile, and they pulsate strongly. The arteries
perform the office of veins, as they convey the adulterated blood
from the fetus to the placenta. It is very rarely that any different
arrangement of the cord from the above, has been observed ; a few
instances have been related where but one artery was present, and
Velpeau has stated that two veins have been met with. The colors
of the blood in the vein and arteries resemble each other so nearly
as to be scarcely distinguishable.

The cord is subject to abnormities and accidents, as, a division
of the vessels before having reached the placenta, a varicose or
hydatidic condition, a rupture of the coats, a closure of the vessels,
an insertion into some other part of the fetus than the umbilicus,
or into a wrong part of the decidua, and twists or knots, especially
when the cord is very long, which interfere more or less with the
circulation and consequent nutrition of the fetus. Any of these
conditions may occasion the death of the fetus, and abortion,
though, some of them, when slight, exert no important influence.
The cord is most commonly above the head of the child, yet there

THE FETUS AND ITS DEVELOPMENT.

213

are often exceptions; it has been found coiled once or twice around
the child's neck, or body, or a limb, in some instances causing death
by strangulation, or the loss of a limb ; occasionally, it is found
presenting before the fetal head. In cases of twins, each fetus has
its own cord, though instances have been met with where there
existed a communication between the cords of the several fetuses.

CHAPTEE XXI,

OF THE FETUS AND ITS DEVELOPMENT.

Fig. 35.

The ovule or ovum is the human egg previous to its impregna-
tion, though these terms are frequently applied to the embryo and
the fetus ; as long as this is amorphous or of an undetermined
form, it has received the name of germ.; from the period when a
definite form can be observed until the third month, it is called the
embryo, from which time until its expulsion from the uterus, the
term fetus is applied to it. After birth it becomes the child or
infant, though either of these latter terms are often used synony-
mously with fetus.

The study and investigation of the de-
velopment of the human embryo (Fig. 35),
is one which the student finds attended
with considerable difficulty; for, notwith-
standing the many discoveries of physiol-
ogists on this point, there still remain much
obscurity and uncertainty attached to it, as
is evident from the various views which
have from time to lime been presented to
the profession. Dr. Bigby, in his work on
Midwifeiy, has probably, given the clearest,
and at the same ti«ie the most concise oped Ovum, in which tiie two
illustration of the researches and conclu- «>*™nMhk embryonic and

- , - . • , -i i UMBILICAL VESICLE — BEGIN TO

sions of those who have investigated the „^kT>

° APPEAR.

subject, as will be found in the following 0. umbilical vesicle,
quotation, which will, I trust, prove ac-
ceptable to nil who are interested :

"Embryo. — There is, perhaps, no de-
partment of physiology which has been so remarkably enriched

Section of a more devel-

I. Internal layer of the Blasto-

derma.
E. External layer.
V. Vitelline Membrane.

214

AMERICAN ECLECTIC OBSTETRICS.

by recent discoveries, as that which relates to the primitive devel-
opment of the ovum and its embryo. The researches of Baer,
Rathke, Purkinje, Valentin, etc., in Germany ; of Dutrochet,
Prevost, Dumas, and Coste, etc., in France ; and of Owen, Sharpey,
Allen, Thompson, Jones, and Martin Barry, in England, but more
especially those of the celebrated Baer have greatly advanced our
knowledge of these subjects, and led us deeply into those mys-
terious processes of nature which relate to our first origin and
formation.

" These researches have all tended to establish one great law,
connected with the early development of the human embryo, and
that of other mammiferous animals, viz.: that it at first possesses
a structure and arrangement analogous to that of animals in a
much lower scale of formation; this observation also applies, of
course, to the ovum itself, since a variety of changes take place
in it after impregnation, before a trace of the embryo can be
detected.

" At the earliest periods, 'the human ovum bears a perfect
analogy to the eggs of fishes, amphibia, and birds ; and it is only
by carefully examining the changes produced by impregnation in
the ova of these lower classes of animals, that we have been
enabled to discover them in the mammalia and human subject.

" As the bird's egg, from its size, best
affords us the means of investigating
these changes, and as in all essential
respects they are the same in the hu-
man ovum, it will be necessary for us
to lay before our readers a short account
of its structure and contents, and also
of the changes which they undergo,
after impregnation. In doing this, we
shall merely confine ourselves to the
description of what is applicable to the
human ovum.

" The egg is known to consist of two
distinct parts, the vitellus or yelk sur-
rounded by its albumen or white; to
the former of these we now more par-
ticularly refer. The yelk is a granular
albuminous fluid, contained in a granu.
lar membranous sac (the blastodermic membrane), which is covered

Fig. 36.

Section of a Hen's Egg within
the Ovary.

A. The Granulary Membrane forming the

Periphery of the Yelk.

B. Vesicle of Purkinje, imbedded in the

Cumulus.

C. Vitellary Membrane.

D. Inner and Outer Layers of the Capsule

of the Ovum.

E. Indusium of the Ovary.

THE FETUS AND ITS DEVELOPMENT.

215

by an investing membrane called the vitelline membrane or yelk-bag.
The impregnated vitellus is retained in its capsule in the ovary,
precisely as the ovum of the mammifera is in the Graafian vesicle.
The whole ovary in this case has a clustered appearance, like a
bunch of grapes, each capsule being suspended by a short pedicle
of indusium.

"In those ova which are considerably developed before impreg-
nation, the granular blastodermic membrane is observed to be
thicker, and the granules more aggregated at that part which cor-
responds to the pedicle, forming a slight elevation with a depression
in its center, like the cumulus in the proligerous disk of a Graafian
vesicle. This little disk is the blastoderma, germinal membrane,
or cicatricula ; in the central depression just mentioned is an
exceedingly minute vesicle, first noticed by Professor Purkinje, of
Breslau, and named after him : in more correct language, it is the
germinal vesicle.

"According to Wagner, the germinal vesi- Fig. 37.

cle is not surrounded by a disk before impreg-
nation ; and it is only after this process that
the above mentioned disk of granules is formed.
By the time the ovum is about to quit the
ovary, the vesicle itself has disappeared, so A
that an ovum has never been found in the ovi- b. Blastoderma.

j , , • . i .i , i . From T. W. Jonet.

duct containing a germinal vesicle, nothing

remaining of it beyond the little depression in the cumulus of the

cicatricula.

"The rupture of the Purkinjean or germinal vesicle has been
supposed by Mr. T. W. Jones to take place before impregnation ;
but the observations of Professor Valentin seem to lead to the
inference that it is a result of that process, and must be therefore
looked upon as one of the earliest changes which take place in the
ovum or yelk-bag upon quitting the ovary.*

"During its passage through the oviduct (what in mammalia is
called the Fallopian tube), the ovum receives a thick covering of
albumen, and as it descends still farther along the canal the mem-
brane of the shell is formed.

" On examining the appearance of the ovum in mammiferoua
animals, and especially the human ovum, it will be found that it

*Wesaid, "one of the earliest changes." Mr. Jones considers that "the breaking
up of the surface of the yelk into crystalline forms,'' is the first change which he has
observed.

216 AMERICAN ECLECTIC OBSTETRICS.

presents a form and structure very analogous to the ova just des-
cribed, more especially those of birds. It is a minute, spherical
sac, filled with an albuminous fluid, lined with blastodermic or
germinal membrane, in which is seated the germinal vesicle or
vesicle of Purkinje. When the ovum has quitted the ovary the
germinal vesicle disappears, and on its entering the Fallopian
tube it becomes covered with a gelatinous, or rather albuminous
covering. This was inferred by Valentin, who considered that
' the enormous swelling of the ova, and their passage through the
Fallopian tubes,' tended to prove the circumstance. (Edin. Med.
and Surg. Journ., April, 1836.) It has since been demonstrated
by Mr. T. W. Jones, in a rabbit seven days after impregnation.
The vitellary membrane seems, at this time, to give way, leaving
the vitellus of the ovum merely covered by its spherical blasto-
derma, and incased by the layer of albuminous matter which
surrounds it.

" From what we have now stated, a close analogy will appear
between the ova of the mammalia and those of the lower classes,
more especially birds, which from their size afford us the best
opportunities of investigating this difficult subject.

" In birds, the covering of the vitellus is called yelk-bag; whereas,
in mammalia and man it receives the name of vesicula umbilicalis.
Its albuminous covering, which corresponds to the white and
membrane of the shell in birds, is called chorion: by the time that
the ovum has reached the uterus, this outer membrane has under-
gone a considerable change ; it becomes covered with a complete
down of little absorbing fibrillte, which rapidly increase in size
as development advances, until it presents that tufted, vascular
appearance, which we have already mentioned when describing
this membrane.

" The first or primitive trace of the embryo is in the cicatricula
or germinal membrane, which contained the germinal vesicle
before its disappearance. In the center of this, upon its upper
surface, may be discovered a small dark line :* 'this line or primi-
tive trace is swollen at one extremity, and is placed in the direc-
tion of the transverse axis of the egg.'

" As development advances, the cicatricula expands. ' We are

* Allen Thompson on the Development of the Vascular System in the Fetus of
Vertebrated Animals. (Edin. New Philosoph. Journ., Oct. 1830.)

THE FETUS AND ITS DEVELOPMENT.

217

indebted to Pander,' f says Fig. 38.

Dr. Allen Thompson, in
his admirable essay, above
quoted, ' for the important
discovery, that toward the
twelfth or fourteenth hour,
in the hen's egg the ger-
minal membrane becomes
divided into two layers o£
granules, the serous and

-i n . t • A. Transparent Area. B. Primitive Traob.

mucous layers of the cica-

tricula ; and that the rudimentary trace of the embryo, which has
at this time become evident, is placed in the substance of the
uppermost or serous layer.' 'According to this observer, and
according to Baer, the part of this layer which surrounds the
primitive trace soon becomes thicker ; and on examining this part
with care, toward the eighteenth hour, we observe that a furrow
has been formed in it, in the bottom of which the primitive trace
is situated ; about the twentieth hour this furrow is converted into
a canal open at both ends, by the junction of its margins (the
plicae primitives of Pander, the lamince dorsales of Baer) : the canal
soon becomes closed at the cephalic or swollen extremity of the
primitive trace, at which part it is of a pyriform shape, being
wider here than at any other part. According to Baer and
Serres, some time after the canal begins to close, a semi-fluid
matter is deposited in it, which on its acquiring greater consis-
tence, becomes the rudiment of the spinal cord; the pyriform
extremity or head is soon after this seen to be partially subdivided
into three vesicles, which being also filled with a semi-fluid matter,
gives rise to the rudimentary state of the encephalon.' 'As the
formation of the spinal canal proceeds, the parts of the serous layer
which surround it, especially toward the head, become thicker and
more solid, and before the twenty-fourth hour we observe on each
side of this canal four or five round opaque bodies ; these bodies
indicate the first formation of the dorsal vertebrae.

" ' About the same time, or from the twentieth to the twenty-
fourth hour, the inner layer of the germinal membrane undergoes
a farther division, and by a peculiar change is converted into the

t Pander, Beitrage zur Entwickelungs-geschichte des Hunchens im Eie. Wurzburg,
1817.

218

AMERICAN ECLECTIC OBSTETRICS.

Fig. 39.

A. Transparent Area.

B. Laminae Dorsales.

C. Cephalic End.

D. Rudiments of Dorsal Vertebra?.

E. Serous Layer.

V. Lateral i'ortion of the Primitive Trace.

G. Mucous Layer.

H. Vascular Layer.

K. Laminaj Dorsales united to form the Spi-
nal Canal.

Fig. 40.

vascular mucuous layers.' (A. Thompson, op. cit.) It will thus
l>e seen, that the germinal membrane is that part of the ovum

in which the first changes pro-
duced by impregnation are ob-
served. The rudiments of the
osseous and nervous systems
are formed by the outer or
serous layers ; the outer cov-
ering of the fetus or integu-
ments, including the amnios,
are also furnished by it. ' The
layer next in order, has been
called vascular, because in it
the development of the principal parts of the vascular system
appears to take place. The third, called the mucous layer,
situated next the substance of the yelk, is generally in intimate
connection with the vascular layer, and it is to the changes which
these combined layers undergo, that the intestinal, the respiratory,
and probably also the glandular systems, owe their origin.' (A.
Thompson, op. cit., p. 298.)

" The embryo is therefore formed in the layers of the germinal
membrane, and becomes as it were, spread out upon the surface of

A. Serous Layer.

B C. Vascular Layer.

D. Mucous Layer.

E. Heart.

THE FETUS AND ITS DEVELOPMENT.

219

the ovum : the changes which the ovum of mammalia undergoes
appear, from actual observation, to be precisely analogous to those
in the inferior animals. (Baer, Prevost and Dumas.) From the
primitive trace, which was at first merely a line crossing the cica-
tricula, and which now begins rapidly to exhibit the characters of
the spinal column, the parietes of the head and trunk gradually
approach farther and farther toward the anterior surface of the
abdomen and head until they unite ; in this way the sides of the
jaws close in the median line of the face, occasionally leaving the
union incomplete, and thus appearing to produce in some cases the
congenital defects of hair lip and cleft palate. In some way the
ribs meet at the sternum ; and it may be supposed that sometimes
this bone is left deficient, and thus may become one of the causes
of those rare cases of malformation, where the child has been born
with the heart external to the parietes of the thorax. In like
manner the parietes of the abdomen and pelvis close in the linea
alba and symphysis pubis, occasionally leaving the integuments of
the navel deficient, or, in other words, producing congenital um-
bilical hernia, or at the pubes a non-union of its symphysis with a
species of inversion of the bladder, the anterior wall of that viscus
being nearly or entirely wanting.

" The cavity of the abdomen is therefore at first open to the
vesicula umbilicalis or yelk, but this changes as the abdominal
parietes begin to close in ; in man and the mammalia merely a part
of it, as above mentioned, forms the intestinal canal, whereas, in
oviparous animals, the whole of the yelk-bag enters the abdominal
cavity, and serves for an early nutriment to the young animal.
Another change connected with the serous or outer layer of the
germinal membrane is the formation of the amnion. The fetal
rudiment, which from its shape has been called carina, now begins
to be enveloped by a membrane of exceeding tenuity, forming a
double covering upon it ; the one which immediately invests the
fetus is considered to form the future epidermis ; the other, of
outer fold, forms a loose sac around it, containing the liquor amnii.
While these changes are taking place in the serous layer of the
germinal membrane, and while the intestinal canal, etc., are form-
ing on the anterior surface of the embryo, which is turned toward
the ovum, by means of the inner or'mucous layer, equally import-
ant changes are now observed in the middle or vascular layer.
* In forming this fold/ says Dr. A. Thompson, ' the mucous layer
is refl ected farthest inward ; the serous layer advances least, and

220

AMERICAN ECLECTIC OBSTETRICS.

Fig. 41.

the space between them, occupied by the vascular layer, is filled up
by a dilated part of this layer, the rudiment of the heart.' (Op.
cit., p. 301.)

" While this rudimentary trace of the vascular system is making
jits appearance, minute vessels are seen ramifying over the vesicula
umbilicalis, forming, according to Baer's observations, a reticular
anastomosis, which unites into two vessels, the vasa omphalo-mes-
eraica. (British and Foreign Med. Rev. No. 1.) These may be dem-
onstrated with great ease in the chick; the cicatricula increases in
extent ; it becomes vascular, and at length forms a heart-shaped
network of delicate vessels, which unite into two trunks, termi-
nating one on each side of the abdomen.

" The umbilical vesicle now begins to separate
itself more and more from the abdomen of the
fetus,merely a duct of communication passing to
that portion of it whichjforms the intestinal canal.
The first rudiment of the cord will be found at
this separation ; its fetal extremity remains for a
long time funnel-shaped, containing, beside a
portion of intestine, the duct of the vesicula um-

b. is a portion of the con- foilicalis, the vasa omphalo-meseraica (the future

vexity of the Amnion, upon A »

which at a, is the Fundus vena portse), the umbilical vein from the col-
or the diminutive Human venoug radicle8 Qf the chorion, and the
Allantois. '

c. The Duct of the vesi- early trace of the umbilical arteries. These last

cula Umbilicalis, dividing j ■. . r -it i

into two intestinal por- named vessels ramify on a delicate membranous
«ons ; and besides this duct sac 0f an elongated form, which rises from the

are two vessels which are „ . . .

distributed upon the vesi- interior or caudal extremity of the embryo, viz. :
cuia umbilicalis and form the allantois: whether this is formed by a portion

a reticular Anastomosis r

with each other.-fYom of the mucous layer of the germinal vesicle, in
Baer- common with the other abdominal viscera, ap-

pears to be still uncertain ; in birds this may be very easily dem-
onstrated as a vascular vesicle arising from the extremity of the
intestinal canal ; and in mammalia, connected with the bladder by
means of a canal called urachus; from its sausage-like shape, it
has received the name of allantois.

" The existence of an allantois in the human embryo has been
long inferred from the presence of a ligamentous cord extending
from the fundus of the bladder to the umbilieus, like the urachus
in animals. But from the extreme delicacy of the allantois, and
from its functions ceasing at a very early period, it had defied all
research, until lately, when it has been satisfactorily demonstrated

V

THE FETUS AND ITS DEVELOPMENT. 221

in the human embryo by Baer and Rathke. *It occupies the space
between the chorion and amuion and gives rise occasionally to a
collection of fluid between these membranes, familiarly known by
the name of the liquor amnii spurius, which, strictly speaking, is
the liquor allantoidis.

" The function of the allantois is still in a great measure unknown.
In animals it evidently acts as a species of receptacuium urinse
during the latter periods of gestation ; but it is very doubtful if
this be its use during the earlier periods. It does not seem directly
connected with the process of nutrition, which at this time is pro-
ceeding so rapidly, first by means of the albuminous contents of
the vitellus, or vesicula umbilicalis, and afterward by the absorb-
ing radicles of the chorion ; but, from analogy with the structure of
the lower classes of animals, it would appear that it is intended to
produce certain changes in the rudimentary circulation of the
embryo, similar to those which, at a later period of pregnancy, are
effected by means of the placenta, and after birth, by the lungs,
constituting the great functions of respiration.

" In many of the lower classes of animals, respiration (or at least
the functions analogous to it), is performed by organs situated at
the inferior or caudal extremity of the animal ; thus, for instance,
certain insect tribes, as in hymenoptera, or insects with a sting, as
wasps, bees, etc. ; in diptera, or insects with two wings, as the com-
mon fly; and also the spider tribe, have their respiratory organs
situated in the lower part of the abdomen. In some of the Crus-
tacea, as, for instance, the shrimp, the organs of respiration lie
under the tail, between the fins, and floating loosely in the water.
Again, some of the mollusca, viz.: the cuttlefish, have the respira-
tory organs in the abdomen. We also know, that many animals,
during the first periods of their lives, respire by a different set of
organs to what they do in the adult state; the most familiar illus-
tration of this is the frog, which, during its tadpole state, lives
entirely in the water.

" As the growth of the embryo advances, other organs, whose
function is as temporary as that of the allantois, make their appear-
ance : these also correspond to the respiratory organs of a lower
class of animals, although higher than those to which we have
just alluded — we mean branchial processes, or gills. It is to Pro-
fessor Rathke (Acta Natures Curios., vol. xiv), that we are' indebted
for pointing out the interesting fact, that several transverse, slit-
like apertures may be detected on each side of the neck of the

222

AMERICAN ECLECTIC OBSTETRICS.

embryo, at a very early stage of development. In the chick, in
which he first observed it, it takes place about the fourth day of
incubation : at this period the neck is remarkably thick, and con-
tains a cavity which communicates inferiorly with the esophagus
and stomach, and opens externally on each side by means of the
above-mentioned apertures, precisely as is observed in fishes, more
especially the shark tribe ; these apertures are separated from each
other by lobular septa, of exceedingly soft and delicate structure.
Ttathke observed the same structure in the embryo of the pig, and
other mammalia: and Baer has since shown it distinctly in the
human embryo. It is curious to see how the vascular system cor-
responds to the grade of development then present: the heart is
siugle, consisting of one auricle and one ventricle ; the aorta gives
off four delicate, but perfectly simple branches, two of which go to
the right, and two to the left side : each of these little arteries
passes to one of the lobules, or septa, at the side of the neck, which
correspond to gills, and having again united with three others, close
to what is the first rudiment of the vertebral column, they form a
single trunk, which afterward becomes the abdominal aorta. In
a short time these slit-like openings begin to close ; the branchial
FlG 42 processes or septa become oblit-

erated, and indistinguishable
from the adjacent parts; the heart
looses the form of a single heart;
a crescentic fold begins to mark
the future division into two
ventricles, and gradually ex-
tends until the septum between
them is completed. It is also
continued along the bulb of the
aorta, dividing it into two
trunks, the aorta proper, and
pulmonary artery : at the up-
per part the division is left in-
complete, so that there is an opening from one vessel to the other,
which forms the ductus arteriosus.* A similar process takes place
in the auricles, the foramen ovale being apparently formed in the
same manner as the ductus arteriosus; these changes commence in

A. Branchial Processes.

B. Vesicula llmbilicalis.

C. Vitellus.

D. Allantois.

E. Amnion.

From Baer.

*In making these observations upon the formation of the ductus arteriosus, we must
request our readers to consider this as still an unsettled question.

THE FETUS AND ITS DEVELOPMENT.

223

the human embryo about the fourth week, and are completed
about the seventh.

" At first the body of the embryo has a more elongated form
than afterward, and the part which is first developed is the trunk,
at the upper extremity of which a small prominence, less thick
than the middle part, and separated from the rest of the body by
an indentation, distinguishes the head. There are as yet no traces
whatever of extremities, or of any other prominent parts ; it is
straight, or nearly so, the posterior surface slightly convex, the
anterior slightly concave, and rests with its inferior extremity
directly upon the membranes, or by means of an extremely short
umbilical cord.

" The head now increases considerably in proportion to the rest
of the body; so much so, that at the beginning of the second
month, it equals nearly half the size of the whole body: previous
to, and after this period, it is usually smaller. The body of the
embryo becomes considerably curved, both at its upper as well
as its lower extremity, although the trunk itself still continues
straight. The head joins the body at a right angle, so that the part
of it which corresponds to the chin is fixed directly upon the upper
part of the breast; nor can any traces of neck v .

be discerned, until nearly the end of the second
month.

" The inferior extremity of the vertical column,
which at first resembles the rudiment of a tail,
becomes shorter toward the middle of the third
month, and takes a curvature forward under tin
rectum. In the fifth week the extremities be
come visible, the upper usually somewhat sooner Diagram of theFe-
than the lower, in the form of small blunt prom- TUS AND Membranes,
inences— the upper close under the head, the iB°UT THE FoUKTH

Vr KEK

lower near the caudal extremity of the vertebral . - . , ^ , ... ,. ,

v A. Vesicula Umbilicahs, ttl-

coluran. Both are turned somewhat outward, ready passing into

. n .1 • n.i 11 .■• the ventricular anil

on account of the size of the abdomen ; the upper rectum intestine at
are usually directed somewhat downward, the G-

. _ B. Vena and artoria Oni-

lower ones somewhat upward, phalo-meseraica.
"The vesicula umbilicalis may still be dis- c- AIlantois 9pringin-

" from the pelvis with

tinguished in the second month as a small vesicle, the Umbilical Arto-

not larger than a pea, near the insertion of the D Em"ery0

cord, at the navel, and external to the amnion. E- Amnion.

From the trunk, which is almost entirely occu- F' Chonon-_l;Voro Cart"-

224

AMERICAN ECLECTIC OBSTETRICS.

pied by the abdominal cavity, arises a short, thick umbilical cord,
in which some of the convolutions of the intestines may still be
traced. Beside these, it usually contains, as already observed, the
two umbilical arteries and the umbilical vein, the urachus, the vasa
omphalo-meseraica, or vein and artery of the vesicula umbilicalis,
and perhaps, even at this period, the duct of communication between
the intestinal canal and vesicula umbilicalis, the fetal extremity of
which, according to Professor Oken's views, forms the processus
vermiformis.

" The hands seem to be fixed to the shoulders without arms, and

Fig. 44.

Diagram of the Fetus and Membkanes, about the Sixth week.

A. Chorion. G. Communicating Canal between the Vesicula Um-

B. The larger Absorbent Extremities, the Site of bilicalis and Intestine.

the Placenta. H. Vena Umbilicalis.

C Allantois. 1 1. Arteria; Umbilicales.

1>. Amnion. K. Arteria? Omphalo-meseraica.

E. Urachus. L. Vena Omphalo-meseraica.

E. Bladder. N. Heart.

F. VeBicula Umbilicalis. 0. Rudiment of Superior Extremity.

P. Rudiment of Lower Extremity.— From Carut.

the feet to adhere to the ossa ilii ; the liver seems to fill the whole
abdomen; the ossa innominata, the ribs, and scapulae, are car-
ti'aginous.

" In a short time, the little stump-like prominences of the
(Xtremities become longer, and are now divided into two parts, the
superior into the hand and the fore-arm, the inferior into the foot
and leg; in one or two weeks later, the arms and thighs are visible.

THE FETUS AND ITS DEVELOPMENT.

225

These parts of the extremities, which are formed later than the
others, are at first smaller, but as they are gradually developed they
become larger. When the limbs begin to separate into an upper
and lower part, their extremities become rounder aud broader, and
divided into the fingers and toes, which at first are disproportion-
ately thick, and until the end of the third month are connected
by a membranous substance analogous to the webbed feet of
water-birds ; this membrane gradually disappears, beginning at the
extremities of the fingers and toes, and continuing the division up
to their insertion. The external parts of generation, the nose, ears,
and mouth, appear after the development of the extremities. The
insertion of the umbilical cord changes its situation to a certain
degree ; instead of being nearly at the inferior extremity of the
fetus, as at first, it is now situated higher up, on the anterior sur-
face of the abdomen. The comparative distance between the um-
bilicus and pubis continues to increase, not only to the full period
of gestation, when it occupies the middle point of the length of
the child's body, as pointed out by Chaussier, but even to the age
of puberty, from the relative size of the liver becoming smaller.

"Though the head appears large at first, and for a long time
continues so, yet its contents are tardy in their development, and
until the sixth month the parietes of the skull are in great measure
membranous or cartilaginous. Ossification commences in the base
of the cranium, and the bones under the scalp are those in which
this process is last completed.

"The contents of the skull are at first gelatinous, and no distinct
traces of the natural structure of the brain can be identified until
the close of the second month ; even then it requires to have been
some time previously immersed in alcohol to harden its texture.
There are many parts of it not properly developed until the seventh
month. In the medulla spinalisjio fibers can be distinguished until
the fourth month. The thalami nervorum opticorum, the corpora
striata, and tubercula quadrigemina, are seen in the second month ; in
the third, the lateral and longitudinal sinuses can be traced, and con-
tain blood. In the fifth we can distinguish the corpus callosum ; but
the cerebral mass has yet acquired very little solidity, for until the
sixth month it is almost semi-fluid. (Campbell's System of Mid-
wifery.)

" About the end of the third, during the fourth, and the begin-
ning of the fifth months, the mother begins to be sensible of the
movements of the fetus. These motions are felt sooner or later,

226

AMERICAN ECLECTIC OBSTETRICS.

according to the bulk of the child, the size and shape of the pelvis,
and the quantity of fluid contained in the amnion ; the waters
being in larger proportionate. quantity the younger the fetus.

" The secretion of bile, like that of the fat, seems to begin toward
the middle of pregnancy, and tinges the meconium, a mucous
secretion of the intestinal tube, which had hitherto been colorless,
of a yellow color. Shortly after this the hair begins to grow, and
the nails are formed about the sixth or seventh month. A very
delicate membrane (membrana pupillaris), by which the pupil has
been hitherto closed, now ruptures, and the pupil becomes visible.
The kidneys, which at first were composed of numerous glandular
lobules (seventeen or eighteen in number), now unite, and form a
separate viscus on each side of the spine ; sometimes they unite
into one large mass, an intermediate portion extending across the
spine, forming the horseshoe kidney.

" Lastly, the testes, which at first were placed on each side of
the lumbar vertebrae, near the origin of the spermatic vessels, now
descend along the iliac vessels toward the inguinal rings, directed
by a cellular cord, which Hunter has called Gubernaculum testis :
they then pass through the openings, carrying before them that
portion of the peritoneum which is to form their tunica vaginalis.

" The length of a full-grown fetus is generally about eighteen
or nineteen inches; its weight between six and seven pounds.
The different parts are well developed and rounded; the body is
generally covered with the vernix caseosa;* the nails are horny,
and project beyond the tips of the fingers, which is not the case
with the toes; the head has attained its proper size and hardness:
the ears have the firmness of cartilage ; the scrotum is rugous, not
peculiarly red, and usually containing the testes. In female chil-
dren, the nymphse are generally covered entirely by the labia, the
breasts project, and in both sexes 'frequently contain a milky fluid.
As soon as a child is born, which has been carried the full time, it
usually cries loudly, opens its eyes, and moves its arms and legs

* The vernix caseosa is a viscid, fatty matter, of a yellowish-white color, adhering
to different parts of the child's body, and in some cases in such quantity as to cover
the whole surface; it seems to be a substance intermediate between fibrine and fat,
having a considerable resemblance to spermaceti. From the known activity of the
sebaceous glands in the fetal state, and from the smegma being found in the greatest
quantity about the head, armpits, and groins, where these glands are most abundant,
there is every reason to consider it as the secretion of the sebaceous glands of the skin
during the latter months of pregnancy.

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 227

briskly; it soon passes urine and faeces, and greedily takes the
nipple. (NsegelS's Hebammenbuch.)

"Thus then, in the space of forty weeks, or ten lunar months,
from an inappreciable point, the fetus attains a medium length
of about eighteen or nineteen inches, and a medium weight
of between six and seven pounds."

CHAPTER XXII.

POSITION, NUTRITION, RESPIRATION, CIRCULATION, DIMENSIONS, AND DEATH OF THE FETUS,

SUPERFETATION.

It was formerly believed that the fetus in utero maintained
a sitting position during the early months of pregnancy, and that
as it progressed in its development, the superior weight of the
head, effected a revolution, so that at the latter period of preg-
nancy its position was reversed, the head being downward; but
this is incorrect, the position of the intra-uterine fetus remains
unaltered from the commencement to the termination of gestation,
no matter what may have been its primary or original position.
Its usual position is with the head downward, the most dependent
part being the vertex; the head is flexed forward so that the chin
rests on the anterior superior portion of the breast; the thighs are
drawn up toward the abdomen, with the knees apart from each
other, and thrown upward so as to strongly flex the legs on the
posterior surface of the thighs; the heels approximate at the
posterior part of the thighs, the feet being usually crossed ; the
arms rest upon the sides of the thorax, while the fore-arms are
flexed and crossed in front of the sternum; the neck and back are
bent forward into a -curve. In this position it constitutes an oval
figure, whose long diameter is about eleven inches, and forms
a line nearly parallel with the long diameter of the uterus; and
we can not conceive of a more easy and compact position for such
an irregular and bulky body.

The cause of the dependent position of the head, which is by
far more common than any other, has given rise to much specula-
tion; it has been supposed to be the result of gravitation — that
the fetus being suspended by the umbilical cord, its heaviest
extremity, the cephalic, would naturally fall downward. Again,
it has been stated to depend upon the instinctive will of the fetus

228

AMERICAN ECLECTIC OBSTETRICS.

itself, which assumes the position as the most convenient for its
intra-uterine existence, and as the most advantageous for an easy
expulsion. Various other reasons have been given, but none of
them are satisfactory, and the subject remains in as much obscu-
rity as ever.

The principal functions of the fetus while in its intra-uterine
condition, are nutrition, respiration, and circulation, upon each of
which a brief notice will be bestowed. In relation to the first,
nutrition, many hypotheses have been advanced ; it is at present
supposed that during the early embryonic life, nourishment is
accomplished by superficial imbibition, or probably by absorption
through the villi of the chorion, and that its sources are, at first,
the vitellus, or the liquid in the umbilical vesicle, and perhaps the
albuminous matter existing between the amnion and chorion; the
amniotic liquid, after its formation, is also considered to contribute
much toward this end, as it contains several nutrient principles.
It is probably absorbed by the cutaneous surface, for acephalous
fetuses, and those with the natural mucous orifices closed, as well
as those which have been born without a placenta or umbilical
cord, have been, with these exceptions, as well developed as the
perfectly-formed fetus. It has also been stated that this fluid is
probably swallowed, or conveyed into the digestive tube, from the
fact that hair and portions of epithelium have been found mixed
with it in the stomach ; and the meconium is supposed to be the
result of digestion. It has also been suggested by Dr. Montgom-
ery, that the milky liquid in the decidual cotyledons, may assist
in the nourishment of the fetus. The placenta has likewise been
thought to assist during the latter months of pregnancy, but this
is rather designed for hematosis than nutrition, and acts as a sub-
stitute for the undeveloped lungs of the fetus, somewhat in the
manner of the gills of fishes, whose blood is aerated by the water
passing through them. It must be remembered that fetal nutri-
tion has continued in instances where the liquor amnii had been
evacuated for weeks, which would seem to indicate some other
source of nutrition ; beside, although meconium, hair, etc., have
been found in the digestive tube, still it appears to me that the
function of deglutition must be very difficult to perform in cases
where inspiration and expiration are absent, as with the fetus.
It will thus be seen that the subject of fetal nutrition is involved
in great obscurity.

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 229

By FETAL RESPIRATION, is meant, not the inhalation and
exhalation of atmospheric air, such as takes place after birth, but
the phenomenon by which the blood in the placenta is modified to
suit it for the purposes of fetal life. As with the function of nutri-
tion, this is also an unsettled and incomprehensible subject. It is
supposed, that although the placenta may be the medium by
which a vivifying principle is taken from the maternal blood and
conveyed to the fetal, yet the materials which form in the latter
and become unsuited to. nutrition, are not removed by the pla-
centa alone, but principally by the liver, which employs the super-
abundance of carbon and hydrogen to form bile, as well as to aid
in perfecting its own development. Respiration and nutrition
appear to exist together, acting in harmony, without disturbing
each other, and both being, probably, performed, through a similar
means, that of absorption.

In the FETAL CIRCULATION, there are several anatomical
peculiarities, not existing in the adult, which it may be proper to
notice : 1. There is a vein termed the ductus venosus, which is sit-
uated at the thick edge of the liver, and communicates between
the umbilical vein and the vena cava ascendens or inferior vena
cava; after birth this vein contracts, closes on the seventh day,
and becomes obliterated. 2. In the center of the septum, between
the auricles, is an oval aperture, called the foramen ovale or fora-
men of Botal; this is furnished with a valve, which it is stated
allows the blood from the vena cava ascendens to pass into the
left auricle, without mingling with the blood of the vena cava
descendens ; after birth, this closes, rarely persisting beyond seven
or eight days — occasionally it remains unclosed during li|e, giving
rise to a morbid condition known as morbus coeruleus. 3. Soon
after the origin of the pulmonary artery, a branch is given off,
which communicates between this artery and the aorta, entering
this latter just below its transverse arch ; it is called the ductus
arteriosus, and after birth gradually closes and becomes obliterated.
4. The umbilical arteries and umbilical vein have been already
referred to.

The fetal circulation is entirely independent of that of the
mother, its blood resembles venous blood, being of a uniform dark
color, and becoming of a bright florid tint as soon as exposed to
the atmosphere ; it contains less fibrin than adult blood, but coagu-
lates on standing; no difference can be perceived between the

230

AMERICAN ECLECTIC OBSTETRICS.

color of the fluid passing in the umbilical arteries and that in the
■umbilical vein. Under the microscope it presents corpuscles,
resembling those seen in the blood of an adult.

The course of the circulation is as follows: The blood is con-
veyed from the ramifications of the umbilical vein in the placenta
to this vein ; through which it passes, traversing its whole length,
to the umbilicus; as soon as it has entered into the abdomen
through the umbilical ring, it proceeds to the longitudinal sinus, or
fissure of the liver, where a portion of it flows into the ductus
venosus which conveys it immediately to the vena cava ascendens;
while the remainder passes through the vena porta into the liver,
circulates through it, and flows into the hepatic veins where it is
collected and also emptied into the vena cava ascendens, just as it
is traversing the diaphragm. It is from thence conducted,
together with the blood conveyed through the ductus venosus, to
the right auricle of the fetal heart, where it meets and probably
mixes with the blood from the vena cava descendens; a portion of
it flows into the right ventricle, while the major portion passes
through the foramen ovale into the left auricle, and then into the
left ventricle, which throws it into the aorta, through which it is
distributed to all parts of the body, but especially to the head and
superior extremities It returns from these superior parts through
the jugular and axillary veins, passes into the subclaviaus, and then
into the vena cava descendens, through which it flows into the
right auricle, then into the right ventricle, and, together with that
portion which passed into the right ventricle without having
entered into the foramen ovale, is thrown into the pulmonary
artery, from which a portion is conveyed to the lungs, while the
major part passes through the ductus arteriosus into the descend-
ing aorta, where it mixes with the blood from the left ventricle,
not required for the head and superior extremities, and flows along
with it to the descending aorta. That portion which entered the lung
through the pulmonary artery returns by the pulmonary veins to the
left auricle, and thence to the left ventricle, and into the descending
aorta, where it mixes as just stated above. A part of the blood in
the descending aorta is distributed to the viscera and inferior
extremities, while the larger portion returns to the placenta,
through the umbilical arteries, there to be revivified, and be again
taken up by the umbilical vein to traverse the same route ae
before {Fig. 45).

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 231

Fig. 45.

Diagram of the Fetal Circulation.

1. Umbilical Cord, consisting of the Umbilical

Vein, and two Umbilical Arteries.

2. Placenta.

3. Umbilical Vein dividing into three branches.
4 4. Two blanches of the vein to be distributed

to the Liver.
■ i. Ductus Venosus, or third branch of the Um-
bilical Vein.

6. Inferior Vena Cava into which the Ductus

Venosus enters.

7. Portal Vein, which returns the blood from

the Intestines, and unites with the right
Hepatic branch.

8. Right Auricle, through which the blood

passes to the left Auricle.

9. Left Auricle,
in. Left Ventricle, through which the' blood

passes to the arch of the Aorta.

11. Arch of the Aorta, from which the blood is
distributed, through its branches, to the
head and upper extremities.

12 13. The Arrows represent the return of the
blood from the head and superior extremi-
ties through the Jugular and Subclavian
Veins to

14. The Superior Vena Cava, to the right Au-

ricle, and in the course of the Arrow,
through

15. The Right Ventricle to
l(j. The Pulmonary Artery.

17. The Ductus Arteriosus, a proper continua-
tion of the Pulmonary artery ; the com-
mencement of the right and left Pulmon-
ary Artery, are seen on each side.

18 18. The descending Aorta, joined above by the
Ductus Arteriosus ; further down it divides
into the common Iliacs, which become the
Umbilical Arteries.

19. The Umbilical Arteries which return the blood along the cord to the Placenta, while the External
Iliacs are continued to the lower extremities.

'20. The External Iliacs ; the Arrows making the return of the venous blood by the Veins to the Infe-
rior Cava. (Neilland Smith.)

From this arrangement of the circulation, it will be seen that the
blood with which the htad and superior extremities are furnished,
is nearly fresh and pure from the placenta, while that flowing
through the inferior parts of the fetus, having previously circulated
through the system, must be less pure ; and this may, probably, be
a reason why the head and superior extremities are more rapidly
developed than the inferior portions of the fetus.

Previous to birth, the proper functions of the lungs are not
required, and they are small, dense, Arm, and unaerated, being
nourished by small branches passing from the pulmonary artery;
but after birth, considerable change ensues, the lungs become more

232

AMERICAN ECLECTIC OBSTETRICS.

or less inflated with atmospheric air, and pulmonary circulation is
established. The foramen ovale is closed by the valve perfected for
this purpose, which closure propels all the blood, entering the right
auricle, from the ascending and descending cava, immediately into"
the right ventricle ; from thence it is propelled into the pulmonary
arteries (which increase in diameter), and passes into the lungs,
where, from the action of the atmospheric oxygen, it is converted
into arterial blood. The ductus arteriosus being now useless, grad-
ually contracts and disappears. The blood from the inferior extrem-
ities, not being able to pass through the umbilical arteries, flows
through the vena cava ascendens into the right auricle and ventricle
of the heart, thence, as above, into the lungs, and the circulation
becomes changed from that of the intra uterine to that of the extra-
uterine or adult. In addition, other changes also occur, the liver
becomes more active, the excretory functions of the kidneys and
intestinal canal become established, and proper digestion of the food
received into the stomach takes place.

The dimensions, appearances, and weight of the fetus at different
periods of its intra-uterine development, have been somewhat
accurately ascertained by various investigators ; and as it is not only
a matter of mere curiosity, but frequently, one of great practical
importance, in a medico-legal sense, to determine the age of the
expelled fetus, it is necessary that the student should be informed
on these points. The following summary of statements of various
observers are therefore presented :

The first distinct microscopic view which can be had of the
embryo is about the third or fourth week; it is oblong, swollen in the
middle, bluntly pointed at one extremitj', obtuse at the other, and
is slightly curved forward ; it is semi-opaque, of a gelatinous con-
sistence, grayish-white color, varying from two to five lines in
length, and weighing one or two grains. It is surrounded by the
amnion, and has a vermiform or serpent-like appearance. Its head
appears as a small tubercle, separated from the body by a notch ;
its mouth is indicated by a cleft ; its rudimentary eyes by two black
points ; its caudal extremity is slender, and a white line may be
observed in it, which indicates the continuation of the medulla
spinalis. The members present nipple-like protuberances ; the liver
occupies the whole abdomen, the cavity of which is opened in front
to a considerable extent ; the umbilical vesicle is very large ; the
chorion is villous, the villosities being diffused over its whole surface.

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 233

At the sixth iveek, its length is from nine to twelve lines ; its
weight from forty to seventy-five grains ; and all its parts are dis-
tinct. The head has greatly increased, and is separated from the
thorax by the depression of the neck; the eyes still appear as two
dark spots ; the mouth presents a small, triangular orifice ; the face
is distinct from the cranium ; the hands, fore-arms and fingers can
be recognized ; the clavicle and maxillary bone present a point of
ossification ; the legs and feet are situated near the anus, which
remains closed ; the umbilicus, for the attachment of the cord,
may be observed, the cord consisting of the omphalo-mesenteric
vessels, a portion of the urachus, a part of the intestinal tube, and
of filaments, which represent the umbilical vessels ; the formation
of the placenta commences ; the chorion and amnion are separated
from each other; and the umbilical vesicle is very large. The
divisions of the vertebrae can be seen, also the imperfect interven-
tricular septum of the heart, and the lungs, which appear as five
or six lobules, in which the bronchii may be distinguished termi-
nating in somewhat swollen cul-de-sacs. Extending from the lung
to the bottom of the pelvis, along each side of the vertebral column,
may be seen two glandular structures; these are the Wolffian
bodies, or false kidneys, and are constituted of an excretory canal
running through their whole length. Alongside of this canal may
be observed another, which becomes, according to the gender of
the new being, either the oviduct or the vas deferens. Both of
these canals empty below into the transitory pouch or cloaca.

In early embryonic life may be seen on each side of the neck
four transverse fissures; these open into the pharynx, are separated
from each other by fleshy bands, and are analogous to the bronchial
arcs of fishes. The aorta sends three or four branches to these
fissures, but which, together with the fissures soon become obliter-
ated, but two on the left side remaining, one of which becomes the
arch of the aorta, while the other forms the common trunk of the
pulmonary arteries ; the first branchial fissure of each side also
remains, and is converted into the external ear. The upper jaw is
composed of a pimple or piece on each side, which gradually approx-
imate and form a single body ; the nostrils are each split down
to the mouth, and are separated by the incisive pimples, but
approach each other, and assume their proper form, as the pimples
diminish in size ; and if the progress of this development is arrested,
hare-lip is the result.

At two months, the embryo is from one and a half to two inches
16

234

AMERICAN ECLECTIC OBSTETRICS.

in length, and weighs from three drachms to nearly an ounce; the
head forms about one-third of it, the eyes are prominent but not
yet covered by the lids, which are still rudimentary; the nose forms
an obtuse eminence, with rounded and separated nostrils ; the
mouth is gaping ; the elbows and fore-arms are detached from the
trunk, and the fingers are isolated, or adhere by a transparent
gelatinous substance ; the rudimentary shoulders and hips are just
observable ; the penis or clitoris is apparent, but can not readily be
distinguished from each other, on account of the length of the
latter. The anus forms a small conical projection, but is imper-
forate, and its location is marked by a dark spot ; the rudiments of
the lungs, spleen, and snpra-renal capsules are observed; the coecum
is placed behind the umbilicus ; the digestive tube is withdrawn
into the abdomen; the urachus is visible; osseous points are ap-
parent in the frontal bone and in the ribs ; the chorion commences
to come in contact with the amnion at the point opposite the in-
sertion of the placenta, which now begins to assume its regular
form; the cord is inserted low down in the abdomen, is infundi-
buliform in shape, and four or five lines in length, and the umbili-
cal vessels commence their spiral twisting; its base contains a
portion of intestine. The umbilical vesicle begins to disappear.
The epidermis is distinguishable.

At ten weeks, the embryo is from one and a half to two and a
half inches in length, and weighs an ounce, or an ounce and a half;
the eye-lids are apparent and cover the eyes, and the lachrymal
puncta are visible; the hips commence to develop themselves, and
the buccal fissure begins its obliteration. The parietes of the
thorax are seen, and the motions of the heart are no longer visible;
the fingers are distinct, and the toes appear as tubercles united by
some soft substance ; the cord assumes the spiral appearance, is
longer than the embryo, is less infundibuliform, is not inserted so
low down, and still contains a portion of intestine.

At three months, the embryo is from two and a half to five or six
inches in length, and weighs from an ounce and a half to three or
four ounces ; the head is voluminous, but bears a better proportion
to the rest of the body ; the eyelids are very distinct, and are in
contact by their free margins ; the pupillary membrane is visible ;
the nose projects; the mouth is closed but perfectly delineated; the
thorax is well formed ; the fingers are completely separated, and
the nails present the appearance of thin membraneous plates ; the
inferior extremities are of greater length than the rudimentary

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 235

tail ; the clitoris and peuis are very long, but the sex may fre-
quently be discriminated by a longitudinal fissure, the edges of
which form the labia pudenda ; the thymus gland, as well as the
supra-renal capsules are present; the ccecum is placed below the
umbilicus ; the cerebrum is five lines in diameter, the cerebellum
four, the medulla oblongata one and a half, and the medulla spinalis
three -fourths of a line ; the two ventricles of the heart are distinct ;
the decidua reflexa and vera come in contact ; the cord contains a
little of the gelatin of Wharton, and umbilical vessels which twist and
form long spiral turns; the placenta becomes completely isolated,
and the allantois, umbilical vesicle, and omphalo-mesenteric vessels
have disappeared.

At four months, the embryo takes the name of Fetus. Its
length is from five to eight inches, and its weight from three to
seven or eight ounces. The skin is rosy, tolerably dense, and
begins to be covered with down ; and a sensible motion may be
perceived in the muscles. The fontanelles and sutures are very
large, and sometimes whitish hairs may be seen on the head; the
face is elongated but imperfectly developed ; the eyes, nostrils, and
mouth are closed, and the tongue and projection of the chin are
observable ; the membrana pupillaris is very evident ; the nails
become more developed; the sex may be recognized; the coecum
is placed near the right kidney ; the gall-bladder commences to
appear ; meconium is found in the duodenum ; the coecal valve is
visible ; the umbilicus is placed near the pubis ; the ossicula audi-
toria is ossified ; the superior part of the sacrum presents points of
ossification ; the decidua serotina is formed ; and the chorion and
amnion are in close contact with each other. A fetus born at this
period might live for several hours.

At five months, the length of the fetus is from seven to ten
inches, and its weight from seven to twelve ounces. The head is
still large, with appearances of hair; white substance in the cere-
bellum ; the nails are very distinct ; the skin is more consistent,
frequently presenting patches of sebaceous matter; the heart and
kidneys are very voluminous ; the ccecum is situated at the inferior
part of the right kidney; the gall-bladder is distinct; points of
ossification are manifest in the pubis and heel ; germs of perma-
nent teeth appear; the meconium has a yellowish-green tint, and
occupies the commencement of the large intestine; the umbilical
cord is longer.

At six months, the length of the fetus is from ten to twelve and a

236

AMERICAN ECLECTIC OBSTETRICS.

half inches, and its weight from twelve ounces to a pound. The
hair is longer and thicker, white or silvery; the face of a purplish-
red; the eyelids somewhat thicker but still in contact, the pupil-
lary membrane also remains, and the eyebrows are filled with
delicate hairs. The skin is better organized, presenting some
appearance of fibrous structure, and sebaceous covering ; the nails
are solid ; sacculi begin to appear in the colon ; the cord is inserted
a little above the pubis ; the scrotum is very small, quite red, and
empty, the testes being near the kidneys; points of ossification
are developed in the divisions of the sternum.

At seven months, the fetus is from twelve and a half to fourteen
inches in length, and weighs three or four pounds. All its parts
are more perfectly developed and better proportioned; the brain
possesses more consistency ; the skin is rosy, thick and fibrous,
with sebaceous covering ; the eyelids are partly open ; the pupillary
membrane disappears ; the iris commences as a simple ring, which
increases in a concentric manner, ultimately leaving an opening
called the pupil ; the nails have not yet reached the extremities of
the fingers; a point of ossification is observed in the astragalus;
the left lobe of the liver is nearly as large as the right ; the gall-
bladder contains bile; nearly the whole of the large intestine is
filled with meconium ; valvulse conniventes begin to appear ; the
coecum is placed in the right iliac fossa; the testicles leave the
kidneys and approach the inguinal ring.

At eight months, the fetus is from fourteen to sixteen or eighteen
inches in length, and weighs four or five pounds. The skin is very
red, covered with long down, and a quantity of sebaceous matter,
called the vernix caseosa, or smegma, which is a secretion of the
fetal skin, and is found more abundantly on some fetuses than on
others ; it is a fat, slippery, viscous substance, of a yellowish-white
color, is insoluble in water, alcohol or oil, and only partially solu-
ble in potash, and is apparently of service, during labor, by aiding
to facilitate the expulsion of the fetus. The pupillary membrane
disappears; convolutions appear in the brain ; the inferior maxil-
lary bone, which was at first very short, is now as long as the
superior ; the nails are much firmer, and reach the extremities of
the fingers; a point of ossification is observed in the last vertebra
of the sacrum ; no center of ossification is presented by the carti-
lage of the inferior extremity of the femur; the testicles descend
into the internal ring, and one is usually contained in the scrotum ;

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 237

generally that on the left side ; the hair of the head is much
darker and longer.

At full term, the fetus is from sixteen to twenty-three inches in
length, and weighs from five to seven, ten, and sometimes even
twelve pounds, the average weight being about six and a half pounds.
The head is covered with a greater or less quantity of hair, vary-
ing in length from six to twelve lines ; the white and gray sub-
stances of the brain become distinct ; the pupillary membrane no
longer exists; four portions of the occipital bone remain distinct;
the external meatus auditorius still remains cartilaginous; the os
hyoides is not yet ossified ; the skin is covered with sebaceous
matter, especially at the flexures of the joints ; the liver descends
to the umbilicus ; the testes have passed the inguinal ring, and are
frequently found in the scrotum ; meconium is found at the ter-
mination of the large intestine ; the center of the cartilage at the
lower extremity of the femur, exhibits a point of ossification.

A full developed fetus is characterized by a ready movement
of the limbs, an ability to cry, and a capability of sucking ; its
mouth, ej^elids, nostrils and ears are open ; the hair, eyebrows and
nails are fully developed ; the cranial bones are firm, and the
edges of the fontanelles are not far apart, the body is of a clear
red color; and the meconium is discharged within a few hours
after birth. The meconium is a semi-fluid, of a dark green color
at term, which is found in the fetal intestines, and is a mixture
of bile with the secretions of the mucous membrane ; some sup-
pose it to be digested amniotic fluid.

An immature fetus may be known by its feeble motions, its
small size, and incapability of sucking ; its head is covered with
down or sparingly with short hair; the bones are soft; the fonta-
nelles widely separated ; the skin is red with blue streaks ; the
nails are not perfected ; the eyelids and mouth are closed ; and the
urination and defecation are imperfect.

As already remarked when treating of abortion, the fetus is
liable to numerous diseases, some of which may be independent
of the condition of the mother, while others occur secondarily
through her. Cases of intermittent fever have occurred to the
fetus where the mother was laboring under the disease ; small-pox
has attacked the fetus both where the mother was suffering with
it, and in other instances where she was entirely exempt from it,
and the same may be said of measles. Various cutaneous diseases

238

AMERICAN ECLECTIC OBSTETRICS.

have also attacked the fetus in utero, as well as hydrocephalus,
pleurisy, abscesses of the lungs, oedema, scirrhous induration,
tubercles, lobular pneumonia, calcareous deposition in the lungs,
peritonitis, and enteritis. It is also especially liable to hyper-
trophy or atrophy, worms, calculus, dropsy, rickets, caries and
necrosis. Various forms of syphilitic disease are very apt to
injure or destroy it, when the system of one or both parents is
contaminated with the syphilitic virus. The heart, liver, kidneys,
stomach, and other organs may become organically affected, and
it is by no means uncommon to observe fractures and dislocations
of various bones, which took place previous to birth. Previous
to the expulsion of the fetus, it is impossible to detect any of these
maladies, and even had we the means of doing so, it is very doubt-
ful whether any curative or even palliative measures could be ben-
eficially pursued; the greater part of them may be ascertained
after its death and expulsion, and all the advantage to be derived
from such information, at this time, is to lead to the adoption of
such measures as may prevent similar attacks in subsequent preg-
nancies.

The signs by which we may determine the death of the fetus, are
frequently of great importance, especially in reference to the best
time for obstetric operations, when these have to be performed.
There are no signs upon which, separately, the accoucheur can
positively determine a dead fetus; indeed its diagnosis is extremely
difficult, and must be decided by the aggregate of symptoms pres-
ent. These are named by Dr. Churchill, in his work on Obstetrics,
as follows:

1. The cessation of the fetal movements; but these may be sus-
pended for several days, and yet the fetus be alive. 2. The
subsidence or flaccidity of the abdomen; this varies much during
pregnancy, less tension being present in women who have had
feveral children. 3. The recession of the umbilicus; but a dead
fetus may remain in utero for months without this sign. 4. The
loose feel of the uterine tumor. 5. A rolling of the tumor in the abdo-
men, and a sensation of dead weight and coldness; these may exist
and yet the fetus be alive, the rolling may proceed from a loss of
tone of the abdominal muscles— women who give birth to a living
child, frequently complain of the uterine tumor feeling as a weight
or foreign body; again, there is no appreciable difference between
the temperature of a living fetus and that of a dead one— the
oldness is a mere sensation that may be experienced independent

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 239

of fetal death. 6. The breasts suddenly become flaccid, and their
secretion suppressed; this rarely occurs from any cause save the
death of the fetus. 7. The health of the female becomes deteriorated ;
but a dead fetus has frequently been retained for weeks or months
without any change in the maternal health, beside the health may
be impaired from other causes. 8. Bad appetite, sunken counten-
ance, a dark areola around the eyes ; fetid, breath, repeated rigors ;
these are all minor signs, and may exist independent of pregnancy,
or when occurring during its presence may be owing to causes not
connected with the condition of the fetus ; yet taken in connection
with other signs they may become useful in aiding the diagnosis.

When the motions of the fetus have been very active up to the
fifth, sixth or seventh month, or longer, and suddenly subside, and
at the same time the breasts which had been firm and 'tense,
become flaccid and decrease in size, while the abdomen loses its
previous tense and rounded form, the uterine tumor becoming
weighty and rolling loosely in the lower belly, we have almost
a positive proof of the death of the fetus, which is rendered still
more certain by the absence of the beating of the fetal heart.
But, although much assistance may be derived from the use of the
stethoscope, yet it frequently proves uncertain, either from want
of tact and experience on the part of the auscultator, or because
the position of the fetus may be unfavorable to the transmission
of sound to his ear, or the pulsations may be temporarily sus-
pended. If, however, the pulsations have been distinctly heard on
a previous occasion, and subsequently become suddenly or gradu-
ally inaudible, the evidence in favor of the death of the fetus, in
connection with the other symptoms, is rendered unequivocal.

After the rupture of the membranes, there are other diagnostic
symptoms of a more determinate character. 1. The liquor amnii
becomes daik, thicker than usual, fetid, and bloody, especially
where the fetus has been dead for some time; but it must be remem-
bered that these conditions have been present with the living fetus.
2. When the death is not recent, having occurred some time pre-
vious to the examination, the scalp will feel emphysematous when
the finger is pressed upon it, crepitating under the touch, and a
portion of the cuticle will peel off; where the death is recent, the
bones of the skull will overlap each other loosely, and the edges of
the bones will convey a sensation of peculiar sharpness. These,
together with [the absence of pulsation at the anterior fontanelle,

240

AMERICAN ECLECTIC OBSTETRICS.

and its decrease from the collapse of the bones, are considered con-
clusive signs.

In face presentations, the flabby lips, flaccid and motionless tongue,
and a slight swelling of the presenting part, are evidence of the
child's death. In breech presentations, the finger can be readily intro-
duced within the sphincter ani in case of death, which contracts and
resists the finger, if the fetus be alive ; the discharge of meconium
is a symptom of no value. In an arm presentation, the pulse at th«
wrist may be imperceptible, the arm may become cold and livid, and
yet the fetus be alive ; but if the epidermis peel off, the child is dead.
In prolapse of the umbilical cord, the absence of pulsation in it is
usually regarded as conclusive evidence of the child's death ; but
this has occurred and the child been born alive.

Before closing this part of the work, I will make a few remarks
on superfetation, which subject has not been noticed in the preceding
pages. By superfetation is meant, a second impregnation and con-
ception, where the female is already pregnant. The early writers
were impressed with the belief, that such an occurrence was possi-
ble, while among recent authors we find a difference of opinion.
The reasons which have been advanced in its favor, are : 1. Females,
at full term of pregnancy, sometimes give birth to a well-developed
fetus, and a blighted ovum at the same time ; or, where the children
are living, one of them will be more matured than the other. The
disparity between them has afforded ground for belief that they
were the products of different impregnations ; but these cases do
not prove superfetation, as it not unfrequently occurs that the
development of one of the twins is retarded, or it may die and be
expelled while the other is retained ; and it is by no means uncom-
mon, for one twin to be larger and more matured than its fellow.

2. Cases have been recorded where the female has brought forth,
at one parturition, two children, one of which was white, and the
other black, or mulatto. But these cases have, so far as I know,
been the result of two coitions, shortly succeeding each other, one
with a white, and the other with a black person. There is abundant
evidence to prove, that superfetation of this kind, is possible at a
very early period of pregnancy; impregnation having taken place
before the formation of the membrana decidua, or before the canal
of the cervix became closed by the tough, gelatinous secretion of
the glandulse Nabothi. But after the formation of these substances,
which effectually prevents any egress into the uterus, I do [not

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 241

believe that conception can occur, unless, indeed, there be some
other route by which the semen can reach the ovaries, independent
of the uterine cavity, and Fallopian tubes.

3. Instances have been related where from three to four months
after the delivery of a well-developed child, another child, as fully
matured, has been born. In some of these cases, the difficulty has
been removed by the discovery of a double uterus. But where
these circumstances have happened with but a single uterus present,
the subject is involved in much obscurity. It may be that the
development of one fetus progressed much more slowly than that
of the other; and when this latter was born, the uterine contrac-
tions having neither destroyed the integrity of the membranes
of the former, nor injured its utero-placental connection, it con-
tinued to remain in utero, until from size, weight, etc., the
uterus was again called into action. It has also been supposed
in cases of single uterus, that this organ may have been divided by
a longitudinal septum, and impregnation effected in each at different
periods ; but this is as difficult, to my mind, as in the previous
instance, unless it be admitted in each, that immaturity of the fetus
favors protracted gestation, and that the contractions of the uterus^
to expel a full grown fetus, do not, necessarily, involve the imme-
diate expulsion of another in utero, but imperfectly developed.

\

PART III.

LABOR, OR PARTURITION.

CHAPTER XXIII.

LABOR.

Labor, or Parturition, is that function by which the matured
fetus, together with its secundines, are expelled from the uterus ;
it occurs at the end of nine calendar months and one week, or
/ibout two hundred and eighty days from the last menstrual ap-
pearance, and about one hundred and forty days after quickening.
A few days, either previous or subsequent to this time, constitute
no material difference. At this period, the hitherto inactive ner-
vous and muscular systems of the uterus become stimulated into
action, causing contractions of this organ, which are always accom-
panied with pain, in a greater or less degree, and which cease only
when the uterus has expelled its contents ; as the contractions are
invariably attended with pain, the terms, labor pains, and uterine
contractions are employed synonymously. As a general rule, labor?
though painful and exposed to danger, may be expected to termi-
nate favorably, and without artificial aid. Tne average duration
of labor is six hours, or according to some authors, four, but which
depends upon the amount of power in action, and the degree of
resistance which is presented. Cases have been known, in which
labor has been completed in ten or fifteen minutes, while with
others, again, from four to seven, and even ten days have passed,
before the fetus has been expelled into the world. The investiga-
tions of M. Quetelet, Dr. Buck, and others, indicate that more
births occur at night than during the day, there being five children
born at night, for every four born during the day ; and also, that
the least number of births occur at midnight, and at noon. Yet

LABOR.

243

these day-births may, in many instances, require the attention of
the accoucheur during the night.

The immediate or exciting cause of labor, is not satisfactorily
understood, though physiologists of all ages have advanced various
theories. Thus, some have attributed it to a supposed struggling
of the fetus, in an endeavor to procure a more adequate amount of
nourishment than is received while within the uterus ; others again,
have supposed it to depend upon the motions of the fetus, in
seeking to relieve itself from its constrained position, to remove
itself to a less elevated temperature ; or, to obtain access to the
atmosphere for the purpose of breathing. But these, or any other
theories which suppose the fetus to be the principal agent in its
own expulsion, are now known to be incorrect ; the fetus is merely
a passive agent in parturition, and a dead one is expelled as easily
as one living. Some, viewing the uterus alone as possessing the
power necessary to effect labor, have supposed, that when no
further development of uterine fiber can take place, the contrac-
tions ensue ; others assert, that they commence as soon as the
antagonizing condition, which exists between the fibers of the
cervix and those of the fundus, are overcome, the latter having the
preponderance of action. But it is unnecessary to enter into an
explanation of all the views which have been promulgated on the
subject ; suffice it to say, that they are all unsatisfactory, and we
are compelled to admit with Avicenna, an Arabian physician of
the eleventh century, "that at the proper time, labor comes on, by
the grace of God;" or, as a medical man once remarked, "it is
involved in as much obscurity as the cause why peaches ripen in
August, and strawberries in June." But though the researches of
physiologists have failed to discover the exciting cause of labor,
they have established the fact, that as with all other uterine
functions, periodicity exists in this also ; as labor manifests itself
at a period corresponding to that of menstruation, and which, but
for the-conception, would have been a menstrual term.

The principal agents, in the accomplishment of parturition, are
the contractions of the muscular fibers of the uterus, aided in ordinary
cases, during the second stage, by the diaphragm and the abdominal
muscles; the expulsory efforts of all these agents finally determine
the evacuation of the uterine cavity, which, when completed, the
organ returns to its non-gravid state, measuring from two and a
half to three inches in length, about an inch and a half in width,

244

AMERICAN ECLECTIC OBSTETRICS.

and a half or three-fourths of an inch in thickness. The pain,
which attends each uterine contraction, is owing to the pressure
these contractions exert upon the nerves of the uterus, and also to
the constant traction upon the circular fibers of the cervix, by the
longitudinal fibers.

The PREMONITORY SIGNS OF LABOR are several; a sub-
sidence, or sinking down of the uterus in the abdomen, is the first, and
probably most striking ; the uterus, which had previously extended
to the epigastric region, sinks lower, and appears to spread out
laterally. This symptom may occur as early as two weeks previ-
ous to the first pains of parturition, but usually, it is observed only
a few days before. The mechanical impediment to respiration being
thus removed, the female experiences much relief, she respires
with greater ease, feels lighter, cheerful, and more comfortable, less
apprehensive, and is better able and more disposed to action and
motion than she had been for some time previously. In those
cases, where nausea, or vomiting, was present from mechanical
pressure upon the stomach, this subsidence at once relieves the
patient from any further disposition to these unpleasant symptoms.

This falling of the uterus generally takes place gradually, so that
several days pass before the patient is aware of it ; sometimes it
occurs suddenly, or in a short time, as in ten or twelve hours. As
the head, covered by the cervix, must enter the brim, to a greater
or less extent, during the above sinking, this is looked upon as a
symptom indicative of a large, or well-formed, pelvis ; being seldom
observed in cases of contracted pelvis. The sinking of the uterus
is usually considered to be the result of the complete eflacement of
the cervix uteri, with a relaxation of the uterine tissue, which per-
mits it to expand laterally. Dr. Meigs considers the womb wholly
passive in the matter, it being pushed downward by the action of
the diaphragm and abdominal muscles. In some females, this
sinking of the uterus is followed by an unpleasant sensation of
weight in the inferior part of the pelvis, with an irritable condition
of the rectum and bladder, occasioning frequent and ineffectual
desires to evacuate these organs, with other unpleasant symptoms,
and which are owing to pressure of the presenting part upon the
bladder, rectum, bloodvessels, etc. These symptoms can not be
relieved by treatment, though when dysury is present, the patient
may urinate freely, by placing herself upon her hands and knees,
with the hips somewhat elevated; tenesmus, when severe, may fre-

LABOR.

245

quently be relieved by an injection of starch, or elm infusion, to
which a few drops of laudanum have been added.

One, two, or three weeks previous to labor, contractions of the
uterus are frequently observed, to which the names of painless
uterine contractions, or fibrillar contractions, have been applied. The
patient experiences a squeezing sensation in the abdomen, which
is unaccompanied with pain, and which occurs at intervals ; during
its presence, if the hand be placed upon the abdomen, the uterus
will be found hard and well-defined. They occur much sooner in
primiparse than in multiparas, and are supposed to be sometimes
occasioned by the child's motions ; it is believed that these painless
contractions produce gradual changes in the cervix and os uteri,
before actual labor commences, and may, possibly, assist in bring-
ing about the subsidence of the uterus.

In connection with the above symptoms, the parts become some-
what relaxed and soft ; though it is very doubtful whether any
relaxation of the pelvic symphysis occurs, as stated by some authors.
With these are frequently other symptoms, of a minor character,
as cramps in the lower limbs, swelling of the labia, increase of
appetite, etc.; all of which, collectively, indicate the approach of
labor. But the symptom upon which we may rely as an evidence
that labor is close at hand, is a mucoserolent discharge, called by
nurses and midwives, " the show:' It is, usually, observed from
twelve to twenty-four hours previous to the commencement of actual
labor, and consists of a greater or less quantity of mucus, of a thin,
or thick and viscid character, colorless, until labor has commenced,
when it becomes mixed with more or less blood. The mucus is an
exalted secretion of the follicles of the vagina, and is not to be
regarded as an indication of labor, unless there be found mixed
with it the gelatinous substance which had previously occupied
the canal of the cervix; and the blood arises from the separation
of the membranes, and rupture of the bloodvessels which pass from
the cervix uteri to the fetal membranes. According to Wigand,
when the mucus is thick and viscid, it is more favorable. It evi-
dently prepares the passages for the exit of the fetus by lubricating
them. It may be proper to state here, that the show is frequentlj-
absent, and also, it is sometimes observed for some days previous
to actual labor; but these cases may be looked upon as the excep-
tions tb the general rule; for it is usually only when the dilatation
of the os uteri has commenced, with descent of the membranes,

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AMERICAN ECLECTIC OBSTETRICS.

that the sanguineous show is seen — it is, therefore, a good sign of
commencing labor.

Some females suffer for a week or longer previous to labor, with
a restless anxiety, a wakefulness at night, pains of an irregular
character about the uterus, and a peculiar nervous irritability.
Others again, especially those of nervous temperament, are attacked
with rigors or tremors, with greater or less severity, but which are
unattended with any feeling of cold. These rigors are usually
indicative of rapid dilatation of the os uteri, and require no atten-
tion, unless accompanied with a sensation of cold. They fre-
quently occur immediately after labor, and are sometimes so severe
as to create some alarm in the minds of the friends of the patient,
as well as of herself, and heating drinks are often injudiciously
administered. Some warm diluent drink, as tea, and an extra cover-
ing over the patient will be all that are required. " If these shiver-
ings be followed by symptoms of fever, this must be guarded against;
if by severe pains in the head and abdomen, evidently not proceed-
ing from the labor, then you may suspect that there is inflammation.
If there be much flushing of the face, throbbings of the carotids,
and the pulse high, there is reason to apprehend that convulsions
may supervene. These accidents are rare, however; and when the
rigors occur without the above accompanying symptoms, it is indica-
tive that the labor will be active and its termination speedy." —
Blundell.

Dilatation of the os uteri is frequently, if not almost always,
attended with nausea or vomiting; these are not the causes, but
the effects of the dilatation, and have no weight in sustaining an
erroneous impression once entertained, that nauseants or emetics
favor dilatation. The only agents proper to overcome a rigid os
uteri, and forward the dilating process, are relaxants. The prac-
titioner, who, in the first stage of labor meets with a rigid os
uteri, which seems disposed to obstinately maintain its rigidity,
notwithstanding the strength and frequency of the pains, will
observe that an attack of spontaneous vomiting is followed by a
softening, relaxation, and dilatation of the os, and is therefore a
favorable symptom. As a common rule, it seldom lasts any
length of time, occasions but little distress to the patient, and
needs no treatment. Occasionally it becomes very painful and
obstinate, requiring the aid of the physician; a few drops of
Laudanum, or of tincture of Gelseminum in a draught of Soda
water, will usually prove sufficient to check it ; and should consti-

LABOR.

247

pation be present, a laxative enema must be administered. It is
rarely that a sinapism is required over the epigastrium ; vomiting
during a protracted labor, must not be confounded with that just
referred to ; it is a very unfavorable sign, and the matter ejected,
will be in large quantity, dark colored, and often fetid ; it will be
noticed under Rupture of the Uterus.

Usually labor commences with pain, but considerable progress
may be made without any pain ; and occasionally the patient
experiences no pain until the os has become fully dilated, and the
suffering attends the expulsive effort only. True labor pains are
intermittent in their character, having an interval of ease between
them; at first they are short and weak, with long intervals, but
gradually become stronger, more frequent, with but little or
no interval between them. They may be suspended by many
causes, as passions of the mind, anger, fear, surprise, grief, etc.;
sudden and unexpected news, or even the entrance of the physi-
cian into the parturient room, has frequently suspended the labor
for hours. The administration of stimulating liquors, which is
rather common with some old nurses, is very reprehensible ; I
have known labor to be suspended for twelve hours, by a draught
of gin-sling, advised for the purpose of easing the pains.

There are two kinds of pain recognized at the commencement
of labor, which are termed true and false pains, and it is of impor-
tance to the patient, as well as to the reputation of the physician,
to be enabled to discriminate between them. True pains are regu-
larly intermittent, and are confined to the uterine region, and
during their continuauce, if the hand be placed on the abdomen,
over the uterus, it will be found to contract and grow harder with
the pain, and to become softer as the pain passes off; upon making
a vaginal examination, the os uteri will be found to contract
during the presence of a true pain, with a protrusion of the mem-
branes, and to dilate during its absence.

False pains, are more frequent in first pregnancies than in subse-
quent ones ; they are irregular or constant, and exert no influence
whatever upon the uterus or os uteri, though contraction of the
abdominal muscles may attend them, and which it is important not
to mistake for uterine contractions. They are very apt to harass
the patient during the night, and disappear through the day; and
may be dependent upon rheumatism or congestion of the uterus,
intestinal irritability, constipation, over-fatigue, etc., and are some-
times attended with febrile symptoms.

248

AMERICAN ECLECTIC OBSTETRICS.

True pains, commence generally in the back, pass around to the
front of the abdomen, as far down as the groin, recur at regular
intervals, gradually increase in frequency and power, and occasion
contractions of the uterus and os uteri, and protrusion of the bag
of waters. False pains, usually commence at the fundus, have a lim-
ited extent, are irregular, and exert no influence on the uterus or os.

To remove false pains, we must endeavor to learn their cause ;
if they be owing to intestinal irritability, or constipation, a mild
purgative, or a purgative enema will answer; if from over fatigue,
rest must be enjoined, and an opiate may be administered, or, what
is better, an infusion of Scullcap, or Valerian; if from rheumatism,
the compound powder of Ipecacuanha and Opium, with an occa-
sional laxative, will remove them; or tinctures of Gelseminum and
Aconite. Ordinarily, an attention to the condition of the bowels,
with the use of some anodyne, as tincture of Lupulin, compound
tincture of Virginia Snakeroot, or the above powder of Ipecacu-
anha and Opium, will be all-sufficient to effect their removal.
Sometimes they will be present with diarrhea; in such cases, the
compound powder of Rhubarb may be given internally, with
injections of the officinal clyster of Opium.

I have met with many cases, in practice, where the pains were
sharp, regular, occurring at short intervals, with dilatation of the
os to nearly the size of a silver half dollar, and everything indi-
cating a speedy labor; when, after waiting a few hours, the pains
ceased, and did not recur again for several days ; the longest time
I have observed to pass in such cases, before the re-appearance
of labor, was two weeks ; I do not pretend to account for these
anomalies.

Labor has been variously classified by different authors, for the
purpose of facilitating an acquaintance with it. The arrangement
which I have adopted, is one followed by several recent writers,
and will be found fully sufficient for all practical purposes; it
divides labor into four classes, viz. :

1. Natural labor, in which the fetal head presents, and where
delivery is effected within twenty-four hours, without the aid of
any artificial power.

2. Difficult labor, also called lingering, tedious, and protracted, in
which the fetal head presents, but where labor continues beyond
twenty-four hours, and may require some medicinal, manual, or
instrumental assistance.

LABOR.

249

3. Preternatural labor, in which some other part than the head
presents, where there is a prolapse of the umbilical cord, or a plu-
rality of children.

4. Complicated labor, in which some serious accident occurs, not
connected with the presentation of the fetus.

From its commencement to its termination, natural labor is one
continued process, marked, however, by certain peculiarities which
have led to a division of it, among obstetricians, into several parts
or stages. The most usual, and, probably, the most natural
division, is that of Denman, who describes labor as consisting of
three stages. The first stage, extending from the commencement
of labor to the full dilatation of the os uteri ; the second stage,
occupying the period between the dilatation of the os, until, and
including, the birth of the child; and the third stage, including the
delivery of the placenta. The time which each of these stages
occupies varies with different patients, according to circumstances.

In the FIRST STAGE OF LABOR, the os uteri will, at an
early period, be found looking toward the sacrum, and will gradu-
ally approach toward the center of the brim as labor advances.
The pains which are present during this stage, are of a peculiar
character, and are variously described by patients, as " grinding,
cutting, or sawing." They are entirely confined to the uterus,
producing no sensible change in the position of the fetus, but
influence the condition of the os uteri, dilating it that the head of
the fetus may pass through. These are termed the preparatory
pains, and the rapidity with which dilatation ensues, very much
depends on their force and frequency. Generally, it proceeds more
rapidly during the latter half of the first stage, and is effected more
slowly in primiparse than in multipara.

These pains commonly commence in the back, extend to the
loins, from thence to the front of the abdomen and pubes, and
terminate in the neighborhood of the groins, or upper part of the
thighs. Sometimes females are able, especially in the first part of
this stage of labor, to conceal these pains, but usually they cause
much suffering, obliging the patient to suspend for the time what-
ever occupation she may be engaged in, and forcing from her
moans, or a short and fretful cry. The pains are not attended
with any bearing down or expulsive efforts, and the practitioner
should be careful to caution the patient against any of these volun-
17

250

AMERICAN ECLECTIC OBSTETRICS.

tary efforts during the preparatory stage of labor, which are so
often unwisely advised by ignorant nurses and midwives. As the
pains proceed, they increase in severity, and last for a longer time,
having shorter intervals between them, and when absent, the
female manifests a certain degree of restlessness and uneasiness ;
the pain in the back may sometimes be relieved by pressure, but
not always, and when this is the case, the matter should be left to
the care of the friends, and not to the practitioner, who must be
careful not to fatigue himself at an early period, lest he be unable
to afford more important aid at an advanced stage, should it be
required. Sometimes each pain is preceded by a slight nervous
tremor or shivering, and it is not uncommon for nausea and vomit-
ing to attend the whole of the first stage. The vomiting is
beneficial, in consequence of its removing crude and indigestiole
substances from the stomach, when they are present, and also from
the relaxation of the os uteri, which is, certain to accompany it.
When it is very severe and annoying, I have frequently checked it
by administering a dose or two of the tincture of Gelseminum.
Frequently the female becomes irritable, restless, impatient, or
despondent, and may say or do things which are extremely
unpleasant to the physician, but which goc-d sense will teach him
to pass by in a pleasant, friendly manner, at the same time
endeavoring to console and encourage his patient. By an atten-
tion to the moans or peculiar cries of the female, her expressio»s,
and respirations, the practitioner can frequently determine the first
from the second stage of labor. Respiration will be free, or if the
breath be suspended, it will be for a few seconds only, without any
straining or bearing down efforts, and which is the reverse of the
second stage.

Generally, there is no increase of the temperature of the surface,
and no perspiration, especially during the first half of this prepar-
atory stage ; and the pulse is seldom quickened until the second
stage. Hohl has remarked, however, that during the first part of
a pain, the pulse will be found 'B more frequent, then remain
stationary for a moment, and afterward subside into its natural
action. Upon auscultation, just as a pain is coming on, there will
be heard, a short, rushing sound, apparently proceeding from the
liquor amnii, and which may, probably, be caused in a degree by
the fetal movements, or the muscular contractions of the uterus, at
the same time all the tones of the uterine pulsations become
stronger and more distinct ; sounds also, are heard which were not

LABOR.

251

noticed before, especially those of a piping, resonant character, and
which seem to vibrate through the stethoscope. As the pain
reaches its maximum, these sounds become gradually dull or
altogether inaudible, and return with the decline of the pain,
resuming the original character during the intervals between the
pains.

If we examine, during the pains, the body of the uterus will be
found hard and rigid, and thrown forward, so as to place its long
diameter in correspondence with the axis of the superior strait^
and without which the labor would progress with much difficulty ;
as the pain ceases, the organ relaxes. An examination per vaginam
will detect the os uteri high up, looking toward the promontory of
the sacrum, and more or less dilated ; most commonly, it will
admit the end of the index finger, at the commencement of labor.
If it be much dilated, each pain will cause a protrusion of the
membranes into the vagina, which is called the "bag of waters" —
and the presenting part, if it be low down, will be found to ascend
during each contraction, but will resume its original position as the
pain subsides.

The bag of waters is the name given to that portion of the mem-
branes which protrudes through the os into the vagina during a
pain. Its shape is generally round or elliptical, and sometimes
elongated, like a sausage, and which is supposed to be owing to the
nature of the presentation. During a pain it is hard, and must be
carefully touched, as it frequently becomes ruptured from the
slightest cause ; as the pain disappears, it becomes lax and wrinkled^
and recedes into the uterine cavity. It undoubtedly assists in the
dilatation of the os uteri. It usually ruptures at its dependent
extremity, and when the rupture occurs, that portion of the liquor
amnii, situated between the fetal head and the membranes, escapes,
the head descends and prevents the too rapid flow of the remainder^
and delivery is soon effected. Sometimes the rupture occurs high
up, the waters escape gradually, and the head being in immediate
contact with the membranes, the child may be born with a caulm
especially when the membranes in contact with its head remain
unbroken. Rupture of the membranes may occur at any period of
the first stage of labor, depending on their power of resistance; if
it should happen at an early period, it will delay the delivery, and
may cause a difficult labor. Sometimes it is not ruptured at all,
but the fetus is born enveloped in the membranes, yet such cases
are rare. It is important for he practitioner, as a general rule, to

252

AMERICAN ECLECTIC OBSTETRICS.

retain the membranes entire, if possible, until complete dilatation
of the os uteri has been effected.

The os uteri may present several variations in its character during
the first stage of labor. Thus, it may be found thick, soft, moist
dilated, or if not dilated, relaxed, and dilatable, which is a favor
able condition ; or it may be thick, hard, rigid — perhaps likewise,
hot, dry, and tender, feeling somewhat like cartilage, and which is
an unfavorable condition, generally indicating a difficult labor.
Toward the latter part of the first stage of labor it may be found
soft, moist, cool, sensitive to the touch, but not painful, and so thin
that the presenting part of the fetus can be distinctly felt through
its substance ; this is likewise a favorable condition. Or, it may be
thin, hard, rigid, perhaps tender when touched, with its edge
tightly embracing the presenting part of the fetus, like a piece of
cord ; this is an unfavorable condition, indicating, as with the
former instance of rigidity, a difficult labor. Rigidity of the os
uteri will be treated of hereafter.

To return to the progress of the preparatory stage of labor; the
os uteri becomes thinner and softer as the labor advances, its
dilatation continues to increase, and usually, the head of the fetus
passes the superior strait, occupying a considerable portion of the
pelvic cavity, until complete dilatation having been effected, the
os uteri is wholly effaced, and the head passes through into the
vagina. Generally, if the membranes have not previously given
way, they rupture at this moment, and the liquor amnii escapes
with a gush. Sometimes they do not rupture but pass through
the vagina and its orifice, upon the external parts, which they aid
in dilating. With the full dilatation of the os uteri, which may
be accomplished in from four to eight hours, the first stage of labor
terminates. The duration of this stage, however, varies with
different women, and frequently with the same women in different
labors, and almost always occupies more time with primiparse.

The os uteri having become fully dilated, the SECOND STAGE
OF LABOR now commences, between which and the first stage,
especially if the membranes have ruptured, there is usually a short
interval of freedom from pain ; and with some women, several hours
of rest will follow without any pain.

A new order of things is now presented, the pains become much
stronger and more perfect, and change from the grinding character
to that of the expulsive, and it is only in this stage that the accea-

LABOR.

253

sory powers of the diaphragm and abdominal muscles are called
into action — the rectus abdominis, the external and internal obliqui,
and the transversalis. The action of these muscles is rarely wit-
nessed until the os uteri has retracted over the head, and then it
commences powerful and continued. The patient fills her chest
with air, and fixes it as a fulcrum for muscular exertion by. closing
the glottis, which prevents the escape of the air ; she then grasps
any object near her for support, fixing the feet firmly upon some
immovable point, and forcibly bears down. Any noise or outcry i3
usually suspended until the termination of the pain, the breath
being held until it is over ; though, sometimes when the pain con-
tinues for a long time, a kind of half-breath with a short cry will be
uttered once or twice during the pain, apparently for the purpose of
more firmly renewing the condition necessary for powerful bearing-
down efforts. The tone is not of the fretful, moaning character of
the first stage, but is of a straining character, sometimes termina-
ting in a short cry and gasping for breath, and affords a good test
for the practitioner to determine the second stage from the first.
Between each pain there is a perfect condition of repose, and should
this stage be much prolonged, the patient will frequently doze
during the intervals. The dozing is owing to fatigue, and partly to
the congestion about the face and head, the result of the suppressed
breathing, and requires no interference, unless it be excessive and
attended with severe pain in the head, which are the premonitory
signs of convulsions.

During the presence of a pain, and while the patient is so pow-
erfully exerting herself, the heat of the skin becomes increased, also
the frequency of the pulse, the eyes are bright, profuse perspiration
takes place, and during the suspension of respiration, the vessels of
the head and neck become congested from an arrest of the circula-
tion, the face being florid and sometimes purple. The patient
manifests much agitation, though she bears her sufferings with
more patience and cheerfulness than in the first stage, and appears
to have changed her fretful or despondent condition to one of cour-
ageous determination. Vomiting frequently occurs in this stage
also, and is usually a favorable symptom, unless it be dark, greenish,
and fetid, with fever, suspension of pains, and tenderness of abdo-
men, when it is a very unfavorable indication.

Upon making a vaginal examination, the head of the child will
be f(3und in the pelvic cavity, each pain forcing it toward or upon
the perineum ; the pressure exerted upon the head causes a wrink-

254

AMERICAN ECLECTIC OBSTETRICS.

ling of the integuments, and overlapping of the parietal bones ; and
if the external parts are unyielding, the labor being protracted, a
tumor, caput succedaneum, will form under the scalp, owing to an
effusion of blood into the loose cellular membrane between the
bones and integuments. The head most usually lies in an oblique
or diagonal position in the pelvis, having the occiput looking
toward the left acetabulum, and the forehead to the right sacro-
iliac symphysis, the most dependent part being the vertex. As the
head is forced onward by the pains, the soft parts of the canal
through which it is passing become gradually dilated, rotation of the
head ensues, the perineum becomes thin and distended, and the
occiput appears between the labia. On the subsidence of the pain
the head recedes, and the external parts resume their natural appear-
ance; but on the return of another pain, the head is thrust still
further down, the distension of the perineum is increased, the anus
projects, and probably there may be, at this time, a discharge of the
contents of the rectum, as well as of the bladder. The patient
suffers most intensely, as manifested by her loud, piercing cries, or
by deep, suppressed groans. As the pains continue, the distension
of the perineum increases, it becomes thinner, tense, elongated, and
widened, the vulva begins to unfold, and the head advances to the
external labia ; with the subsidence of the pains the elasticity of the
perineum forces the head to recede upward, to be again thrust for-
ward upon their renewal. Finally, all resistance is overcome, a
succession of strong expelling pains, called double pains, because
they follow each other so rapidly, that a new one commences before
the previous one has terminated, causes the head to emerge from the
vulva, while, at the'same time, the female utters a sharp, agonizing
shriek, which is followed by panting and sobbing, and, after a short
period of repose, the remainder of the child is delivered. As soon
as the head is born the child commences respiring and crying, or if
this does not immediately occur, it will as soon as the mucus in the
mouth is removed by means of a finger.

Dilatation of the perineum, like that'of the os uteri, is accom-
plished in different cases, at various periods of time, sometimes
requiring several hours before it is completed, especially in first
labors, and as often requiring only a few pains. Its distension is
so great during the passage of the head and shoulders as to
endanger its laceration, which must be carefully guarded against
by the practitioner.

MANAGEMENT OF NATURAL LABOR.

255

After delivery of the child, the female is relieved from all her
suffering and anxiety, and enjoys a greater or less period of repose,
until the THIRD STAGE OF LABOR commences : though,
usually, she will be much excited or exhausted, with a rapid pulse,
flushed countenance, and profuse perspiration. The pains are
again renewed, but with less severity than before, and after one or
two have been experienced, the placenta and membranes are
expelled. Sometimes the placenta is delivered with the same pain
that expelled the child, but usually from a few minutes to half an
hour or longer, elapses before this takes place ; as the placenta is
not, commonly, completely detached before the birth of the child.

The delivery of the placenta is usually followed by a variable
amount of blood, not to exceed a pint in normal cases ; and fre-
quently a- shivering, with chattering of the teeth ensues, which,
however, is not the result of cold. When the placenta is not deliv-
ered within an hour after the birth of a child, it must be managed
as a retained placenta. If the distance between the perforation
in the membrane, through which the fetal head passed, and the
placenta, be ascertained after their expulsion, it will give us the
exact distance between the placenta and os uteri, and thus enable
us to estimate the situation of the placenta in utero.

After the secundines have been expelled, the uterus contracts,
and gradually returns to its normal, unimpregnated condition, and
it may be felt through the abdomen soon after the delivery, impart-
ing the sensation of a hard, round tumor, somewhat like a large
ball. For a few days subsequently, the exposed vessels of the
uterus, at the placental site, discharge a sanguineous fluid called Aie
lochia, which changes to a greenish, or a creamy hue, having a
peculiar odor, and which gradually disappears as the uterus resumes
its non-gravid state.

CHAPTER XXIV.

MANAGEMENT OF NATURAL LABOR.

It must be remembered by the practitioner, that labor is not a
case of sickness, but a function natural to females, for which as
complete provision is made as for any other function of the
system ; and all that he can do is, to carefully witness and super-

256

AMERICAN ECLECTIC OBSTETRICS.

intend its progress, without any improper, or uncalled for interfer-
ence. Indeed, the maxim of every obstetrician should be, " allow
nature to pursue her own course, without any officious intermed-
dling." But, sometimes, as is the case with other functions, this
of labor may fail from certain causes, and it is only in these fail-
ures, when the natural powers are inefficient to safely finish the
labor, that the aid of the practitioner is demanded ; and it is his
duty to thoroughly inform himself relative to all the circum-
stances which may require his assistance, as well as the means of
removing, or overcoming them, in the safest, gentlest, and most
successful manner. In a natural labor, nothing further is required,
after having satisfied one's self that the presentation and condi-
tion of the parts are normal, than to patiently await the expulsion
of the head, receive it and the rest of the child, tie and separate
the cord, and remove the placenta. But as the young physician,
especially, ma}^ be at a loss how to proceed in the management of
a case of this kind, I shall lay down a line of conduct, an atten-
tion to which, I trust, will be found advantageous ; for without a
knowledge of the proper course to be pursued, a very slight inter-
ference of an improper character, may convert a simple case of
labor into a protracted, or even dangerous one.

Having been engaged to attend a female in her confinement, the
physician should endeavor so to arrange his business, that, at the
expected time, he can readily be found by those who are dispatched
to summon his presence to the parturient chamber. He should
obey the summons as promptly as possible, not only that he may
secure the confidence of the patient and her friends, by displaying
a readiness, cheerfulness, and willingness to accord his services,
but more especially that he may be in time to rectify any accidents
which may occur, and to which all females are liable during par-
turition— as, presentation of the superior extremities, uterine hem-
orrhage, and (in cases where delivery takes place rapidly, with but
a few paint?), an encircling of the neck of the child by the umbilical
cord. If he reside in a city, it is hardly necessary to take along
with him any medicines or instruments, lest he be tempted to
needlessly administer the one, or rashly employ the other; beside,
when either are required, they can readily be obtained, and in suffi-
cient season. Perhaps a flexible male catheter, aud some com-
pound powder of Ipecacuanha and Opium, may be the only excep-
tions to this rule. But with a practitioner in the country, who
frequently has to attend patients many miles distant from his office,

MANAGEMENT OF NATURAL LABOR.

257

and where the delay occasioned by sending for the requisite articles
may prove fatal to his patient, the case is entirely dififerent. He
should take with him, his instruments, and several vials, contain-
ing compound powder of Ipecacuanha and Opium, Laudanum,
Ergot, Black Cohosh, some preparation for uterine hemorrhage,
and tincture of Gelseminum, or compound tincture of Lobelia and
Capsicum. The use of any of these may not generally, be needed;
but if one patient among fifty is saved, or benefited, the physician
will be fully repaid for his attention to these points.

On reaching the patient's house, he should have his arrival made
known to her before he enters the room, as it is frequently the
case, especially in first labors, thatTthe sudden introduction of the
physician has caused a suspension of the pains for some time ;
beside, the female may wish to have her room arranged before the
entrance of the physician, or she may be very averse to his pres-
ence, requiring some time for her friends to remove her scruples.
But this can not always be done, for with the poorer classes, who
occupy but one room, he is obliged to be ushered into the patient's
presence at once, and his good sense will teach him how to conduct
himself in such cases. Unless from the general symptoms and
appearance of the patient, he suspects the second stage of labor
to be at hand, or where symptoms are present which demand his
immediate attention, it will be proper to remove any embarrass-
ment under which she may be laboring, and allow her to collect
herself, by entering into conversation with her upon any subject
foreign to her situation. Should the pains come on, while thus
engaged, if they are of trifling importance, the practitioner may
leave the room, or occupy himself in conversation with some of
the friends present, and especially with the nurse, from whom he
may gain information as to the condition of the bowels, bladder,
and previous character of the pains. But if the pains are frequent
and active, or occasion much complaining, he may then inquire
of the patient, herself, in a low tone of voice, relative to these
points ; and he may also form some idea of the probable advance
of the labor from the character of the pains. He should likewise
interrogate as to the general health of the patient, and the char-
acter of previous labors ; ascertain the present condition of the
pulse, skin, and tongue, and make such other inquiries as may be
necessary.

If the bowels are in a constipated condition, in the early part
of the first stage of labor, a mild cathartic may be administered,

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as castor oil: but if the labor has advanced to nearly the com-
mencement of the second stage, or if this stage is already present,
a laxative injection should be used in preference, as being more
apt to cause a speedy evacuation of the rectum. And at all times,
during the labor, whenever the female desires to evacuate tlve blad-
der or rectum, the practitioner should leave the room; indeed*
it is proper that he should request the patient, through the nurse,
or some friend, not to retain these discharges, but to have him
notified, whenever they are called for, while he is in the room,
that he may retire.

As soon as it is deemed necessary to make a vaginal examina-
tion, and which should not be delayed for too long a time, the request
must be made of the patient, through some friend or the nurse ;
the object of such an examination is usually understood, but where
it is not, an explanation should be given, stating that it is " for the
purpose of learning the condition of the parts, the manner in
which the child is coming, and to know that everything is right
to insure a safe delivery." Sometimes, an objection is made,
especially by those in their first labors, but by a firm and gentle
course, representing to the patient, that her own safety, as well as
that of her child, may depend upon an early examination, the
objections will generally be overcome. Should the female be pet-
tish, or fidgety, and notwithstanding these representations, persist
in her objections, declaring that she will never submit to an exam-
ination, and perhaps using harsh words to the physician, all that
he can do, will be to wait patiently until the pains have subdued
her caprices and antipathies, when the examination will be cheer-
fully granted. Generally speaking, however, there will be found
no difficulty in obtaining the consent of the patient, if the request
be delicately made through a third (female) person.

One other reason for requiring an early examination, is, that the
accoucheur may not be detained for hours, waiting upon false
pains. I have known several young practitioners, who, having
been misled by these pains, and a delicacy as to insisting upon
a vaginal examination, have been deprived of their rest for many
hours, and were only made aware of their error, when the loss of
confidence in their abilities determined the patient to send for
another medical man, who at once explained the cause of the
delay. Truly, a mortifying situation for any one to be placed in!

It is not only highly proper, but it is a positive and imperative
duty of the practitioner, to conduct himself, throughout the whole

MANAGEMENT OF NATURAL LABOR.

259

course of parturition, with firmness and kindness, but especially
with decorum, using no language, and manifesting no actions
which might offend the delicacy or modesty of the most fastidious.
It will, therefore, be proper for him to observe the persons who are
in the room, previous to making an examination, prudently dis-
missing all but two or three, whose presence as assistants may
subsequently be needed ; and unmarried females should by no
means be allowed to remain, as they can render but little assist-
ance, or afford but a small share of consolation to the patient.
The presence of relatives should always be preferred, and if the
husband remains it is an attention which many men neglect to pay
to their wives at this period, and should be rather encouraged than
condemned ; his presence will tend to check the obscene language
of the filthy-minded, should any such be present. No pure-minded
nor well-meaning practitioner would hesitate for a moment to per-
form all the necessary duties of his profession in the presence of
a husband, which he would do in his absence, or in the presence
of females. A servant in attendance, to do the errands that may
be requisite, will be found a valuable acquisition, when one can
be had.

Previous to the examination, the physician must see that the
nail of the finger to be introduced into the vagina is short, other-
wise, it might, by coming into contact with the tense membranes,
at this early period, rupture them, and occasion serious results.
Indeed, a physician with long nails, and kept in a state of unclean-
liness, is not a very proper nor desirable object for the parturient
chamber. Filthiness of person, in any respect, implies filthiness
or carelessness in practice.

There are various positions recommended for plasing the female
in during an examination, but the one I prefer, in the early part of
labor, is to have her lie on the bed, upon her left side, her back
being toward the physician, with the hips near to the edge of the
bed, and the knees drawn up toward the abdomen, and separated a
little by a pillow, or cushion, placed between them. Other positions
may be advised, as to lie upon the right side, or upon the back, in
which case the right or left hand may have to be used ; but an
accoucheur should accustom himself to examine reaTlily, with
either hand. The position having been taken, the index or middle
finger is to be anointed with lard, sweet oil, pomatum^ or other
unctuous substance, both for the purpose of an easy introduction,
and that the parts may not be readily irritated by its presence, as

260

AMERICAN ECLECTIC OBSTETRICS.

well as to guard against the contraction of disease, should any be
present. A cloth, or napkin, should be at hand, as likewise a basin
of water, soap, and towel, for the subsequent washing of the hands.
In all cases, when possible, never make a vaginal examination,
unless in the presence of a third person.

Having loosely thrown a sheet over the patient, for any exposure
of her person is unnecessary and reprehensible, the practitioner
will seat himself by the bedside in such a manner as will admit a
ready introduction of the finger into the vagina, that is, with his
face looking toward the head of the patient, and his side to the
side of the bed next the patient. As simple as this direction
may be, an error or a hesitation as to the proper mode of placing
the chair, may destroy the confidence of the patient or her
friends. During the presence of a pain is the period generally
advised for the introduction of the finger, hence, it is frequently
termed " taking a pain." The sheet is now to be raised, but
without any exposure of the female, and the examining hand of
the accoucheur passed quickly upward toward the vagina; the
finger is to be carefully and slowly introduced along the posterior
commissure, and into the vagina, carrying it along the posterior
wall of this canal, until its upper extremity is reached; then,
by bringing the point of the finger toward the symphysis pubis,
the os uteri will be felt. The practitioner will be very careful,
in this examination, not to introduce his finger into the rectum
instead of the vagina, a very mortifying accident, and one which
I have known to occur in the early obstetric practice of some
young medical gentlemen ; it will not be likely to happen, if
presence of mind is retained, with a freedom from restraint and
bashful diffidence. The advice to envelop the arms in a towel,
or cover them with oil-silk sleeves at this early examination, is
altogether unnecessary.

In this first vaginal examination, there are several conditions to
be ascertained, in effecting which, the physician must proceed
carefully and cautiously, and without undue haste ; nor must he
remove his finger, until he has positively satisfied himself in relation
to the more important symptoms. A great fault with young
practitioners, is a species of delicacy or bashfulness, which,
although highly commendable, is very apt to prompt them to make
a hurried and unsatisfactory examination. The knowledge to be
acquired is : 1, whether pregnancy exists ; 2, whether the woman
be in labor, and the progress it has made ; 3, which is the present-

MANAGEMENT OF NATURAL LABOR.

261

ing part of the child ; 4, whether the membranes are entire, or
have ruptured ; 5, the condition of the os uteri, vagina, perineum,
and pelvic diameters.

The recommendation to ascertain the existence of pregnancy in
a female who declares herself pregnant, that she has felt the
motions of the child very sensibly, and that she is suffering from
labor-pains, may, at first sight, appear rather absurd, but when we
reflect that instances have not unfrequently occurred, in which the
physician, misled by the professions of the woman, who was her-
self deceived in regard to her condition, has remained in attendance
for days and even weeks, until the discovery was made that she
was not even pregnant, rendered him the mark for the jest and
ridicule of all who heard of his exploits; this caution will be
deemed very proper and essential. Many circumstances may
occasion an enlargement of the abdomen, as flatulency, an effusion
of fluid in the peritoneal cavity, tumors, etc.; and a near resem-
blance to labor-pains may be occasioned by spasmodic action of
different muscles, leading the female to believe, not only that she
is pregnant, but that labor has actually commenced. It will, there-
fore, be readily understood, that the accoucheur can place no reli-
ance upon any other source than a correct, personal examination.
The means by which pregnancy may be determined have already
been given in Part II, page 101 ; but it may not be amiss to call
attention to a few matters relating thereto. In many instances,
the hand placed on the abdomen for the purpose of detecting the
contractions of the uterus during the pains, the condition of the
abdomen as to its softness or hardness, and elasticity, the extent
of the swelling, and its shape, will frequently decide the question ;
but if there still remains any doubt, the vaginal examination
will be more likely to solve it. There will be found, if pregnancy
be absent, the protruding, unexpanded cervix, with a close,
undeveloped os uteri, and the uterus when poised on the end of
the finger, will, if not diseased, be found small, light, and very
movable ; but, if pregnancy be present, and labor commencing, the
cervix will be found expanded, and the os uteri fully developed,
and perhaps sufficiently open to allow the finger to enter, and
detect the presence of the fetus. When doubt still remains,
ballottement, auscultation, and the means previously recommended
should be resorted to.

The female may be pregnant, but hot in labor, and this is to be
determined by the rules given in the previous chapter. This is a

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AMERICAN ECLECTIC OBSTETRICS.

point that must, as well as the preceding, be fully solved, or else the
practitioner may subject himself to much ridicule by waiting upon
" false pains " instead of true ones, a circumstance which has,
unfortunately, happened more than once in practice. Labor may
be detected by the true pains hardening the uterine globe;, by the
os uteri contracting during the presence of a pain, and dilating
during its absence ; by the bag of waters being tender, tense and
protrusive during the uterine contractions, and becoming soft and
relaxed in their absence, receding within the uterine cavity.

During the presence of a pain, a careful examination should be
made to ascertain the effect produced by it upon the os uteri ;
whether this is high up in the pelvis, or low down ; whether it is
thin, soft, and yielding, or thick, rigid, and unyielding; and in
doing this, no pressure should be made upon the membranes, lest
the}' rupture, and a natural labor be thereby converted into a pro-
tracted one. Upon the cessation of the pain, as soon as the os
uteri has relaxed, and the membranes have collapsed, and not before,
cautiously introduce the finger within the orifice of the os uteri, to
ascertain whether the head presents, and should a pain come on,
while the finger is within, gradually remove it as the membranes
protrude, without exerting any pressure upon them, and re-intro-
duce it on the subsidence of the pain and collapse of the membranes.
The head may readily be known by its rounded form, its peculiar
hardness, and its sutures. If the hard edges of the parietal bones
can be felt along the sagittal suture, there can be no difficulty in
determining the presentation. The endeavor to ascertain the posi-
tion of the head at the commencement of labor, or previous to the
rupture of the membranes and completion of the first stage, is
unnecessary, and exceedingly improper, and endangers the rupture
of the membranes ; it is sufficient to know 'positively that the head pre-
sents, and this information should always be obtained before with-
drawing the finger, for^it quiets any fears or anxiety on the part of
the practitioner, who knows, that nature is most generally capable
of overcoming or rectifying any improper positions of the head
without artificiaUinterference. "Any attempt to determine in
which of the numerous positions described by some authors, the
head is placed at the brim of the pelvis, would only endanger the
rupture of the membranes, and disturb the regular order observed
by nature in the process. Indeed, I can not discover what benefit
could result from knowing during the first stage of labor, provided
you can touch the vertex with the point of the finger, in which of

MANAGEMENT OF NATURAL LABOR.

263

the six or eight positions of Baudelocque and other foreign authors,
the head is placed. The importance attached by some authors to a
knowledge of these positions, some of which are wholly imaginary ?
has probably arisen from the dangerous 'practice of employing the long
forceps before the os uteri is fully dilated, and before the head has
passed into the cavity of the pelvis. At this early stage of the labor,
no instrument of this description can be safely used, and if the opera-
tion of turning were required, the position of the head would have
no influence upon the method we would adopt in turning. Be sure
that the head presents before you state this to the nurse or patient,
as they will not soon forget your mistake, if it should turn out to be
a case of nates presentation." — Lee.

Should any other part present than the head, the practitioner, has
by the examination, gained information which will enable him to
give the necessary assistance at the proper time ; but by neglecting
to obtain this knowledge, he is highly culpable, as he not only runs
the risk of exposing his patient to much unnecessary suffering, but
may actually endanger her life, that of the fetus, or the lives of
both. The method of determining face, nates, and other presenta-
tions, together with their treatment, will be described hereafter. I
may state here, that if the index finger fails to reach the os uteri, or
feel the presenting part, two fingers, the index and middle, should
then be introduced, for it is imperative that the practitioner should
decide the presentation at as early a period as possible. It is fre-
quently the case, especially in females of irritable habits, that the
most cautious introduction of the finger within the os uteri will
occasion the uterus to contract; and in nearly all patients, the
excitement produced by the finger being needlessly moved round to
discover the position of the presenting part, will induce contractions,
which may, more or less suddenly, force the membranes against the
finger and rupture them, occasioning a premature discharge of the
liquor amnii, an accident always to be dreaded in the early part of
the first stage of labor. When the membranes are entire, the pro-
truding bag of waters will be felt during the pain, aud there will be
no dribbling away of the liquor amnii ; if they be ruptured, the pre-
senting part can be more readily detected, the hairy scalp puckering
up during the pain, and becoming smooth and even when it sub-
sides; while, on the contrary, the membranes are smooth and tense
while the pain is on, and lax during its absence.

The finger being withdrawn from the os uteri, the dimensions of
the pelvis and its conditions, should then be explored, for the pur-

264

AMERICAN ECLECTIC OBSTETRICS.

pose of determining the probable character of the labor. The point
of the finger should be carried toward the promontory ot the
sacrum, as explained when describing the pelvic diameters, and if
this be not touched, the space is ample enough for the passage of
the fetus, and if deemed necessary, the other diameters may be
ascertained by the rules heretofore given. The condition of the soft
parts, as to whether they are hot or normally cool, dry or moist,
soft and yielding, or hard and unyielding, should also be observed —
the finger should then be withdrawn, wiping it with the napkin,
while still under the sheet ; after which, the hands may be washed.

As soon as the examination is finished, the patient and her friends^
being naturally anxious to know whether everything is right, will
interrogate the physician relative thereto. This is a very delicate
position for him to be placed in, for if the reply, or opinion expressed,
prove incorrect, the confidence which the parties repose in him, will
be at once lessened or altogether destroyed, and another medical
man may be sent for ; beside which, it^may give rise to some appre-
hensions on their part, that difficulty or danger in the case exists,
not recognized by the medical attendant. Consequently, a reply to
such interrogations should be very guarded ; the physician should
never permit himself to be betrayed into the expression of a posi-
tive opinion on this subject. When the head presents, and every-
thing appears to be in a favorable condition, he may state this, and
add, that if no unforseen circumstances occur, and the labor pro-
gresses uninterruptedly, she will, probably, be delivered by such a
time, naming the longest possible time suggested by the examina-
tion ; and if delivery is effected previous to this time, it will prove
anything but a disappointment to the patient, and will occasion no
doubt of the accoucheur's skill or acquaintance with his profession.
The reasons for such a course are sufficiently obvious ; for it fre-
quently happens that a labor which commences rapidly and with a
prospect of speedy termination, becomes protracted during its latter
part; and one that has a slow and tedious beginning, may advance
with rapidity during the second stage ; beside, many circumstances
may transpire during the progress of labor, which may convert it
into one of a p*rotracted and even dangerous character. By remem-
bering the following points, which have been laid down by ac-
coucheurs, a pretty accurate estimate as to the duration of labor
may be^formed, when not interfered with by unexpected accidents.

1. First labors are commonly more tedious than subsequent ones.

MANAGEMENT OF NATURAL LABOR. 265

2. Labor advances more rapidly where the pelvis is of large
dimensions than where it is small.

3. In proportion to the softness and yielding of the soft parts,
will be the rapidity of the labor.

4. The duration of labor is always modified by the character of
the pains.

5. Labor will be accomplished at an earlier period when the os
uteri is dilated, or thick, soft, and dilatable, than when it is thin and
firm, even though somewhat dilated.

6. A soft and slightly dilated os uteri, moist and relaxed condi-
tion of the soft parts, and regularity in the pains, are signs of a
speedy delivery. When these symptoms are present, and the os
uteri is dilated to a size corresponding in diameter to that of half
a dollar, most accoucheurs consider it improper to leave the patient,
especially if it be in the night — and which will be found a good
general rule to adopt in practice.

7. Labor will be rapid where the vagina is large and yielding
throughout its whole extent ; but will be slow where it is small
and unyielding. " If the entrance of the vagina is small, the
neighboring parts cool, dry, inelastic, and as if tightly drawn over
the bones ; if the finger, in spite of being well oiled and carefully
introduced, produces pain upon the gentlest attempt to examine,
we may expect a tedious and difficult labor."

8. When the upper portion of the vagina is well dilated, and its
lower portion is rigid and contracted, the labor will be rapid
during its first half and protracted afterward ; and vice versa.

9. Labor is almost always tedious in primiparse of advanced
years.

10. Notwithstanding all the above points, unexpected changes
may occur which will materially alter the character of the labor,
and hence the necessity of expressing an opinion, as to the dura-
tion of labor, with a cautious reserve ; for " no one can know
beforehand, when a labor shall be terminated," and no good prac-
titioner ever makes prognostics. Should the examination, at any
time during the first stage of labor, discover rigidity of the parts,
it must be treated as described under difficult or protracted labor.
If the breech, an arm, or any other unusual part presents, it should
be made known to the nurse, or some friend, but not to the patient,
and the proper means should be pursued, as hereafter laid down.

The examination being over, the condition of the patient's bow-
els and bladder must be attended to, using the catheter to evacuate
18

266

AMERICAN ECLECTIC OBSTETRICS.

this latter organ if required ; and it must be recollected, that these
are essential and necessary measures to insure a safe and speedy
delivery. Now is also the time to make the proper arrangements
for the delivery, as preparing the bed, and getting in readiness the
ligatures, scissors, bandage, etc. ; an attention to these little but
very necessary matters, serves to secure the confidence of the
patient and her friends, a very important desideratum in obstetric
practice. The adjustment of the bed is usually attended to by the
nurse, still it is requisite for the practitioner to understand the
method of doing it, as he will frequently be called upon to give
directions in relation thereto. A cot, hair-mattress, or straw-mat-
tress may be used, but by no, means a feather bed; and, if the
patient have but the one feather bed, it must be removed or rolled
to one side, that the under mattress may be used for her to lie
upon. Over this a folded sheet, blanket, or any soft material, to
protect the mattress or cot from the discharges, must be placed,
covering that part of it which will be occupied by the patient's
hips. During the second stage of labor, some recommend a piece
of oil-cloth, or leather, or india-rubber cloth — these are all proper,
but are not always at hand. Upon the folded blanket, or material
that is employed, the sheet upon which the patient is to lie, may
be placed. Care must be taken that in preparing or guarding the
bed, as it is sometimes called, no depressions or concavities are
formed, into which the pelvis might sink down ; at this point it
should rather be elevated a little. Thus arranged, the bed is ready
for the delivery when it comes on.

A piece of narrow tape, or bobbin, or linen thread doubled, two
or three times, and a few inches in length, must be secured for
a ligature. I generally use two ligatures, and which, together
with a pair of sharp scissors, should be placed in a convenient
position for the practitioner to reach, when it becomes necessary
to ligature the umbilical cord and divide it; or these may be
handed to him by one of the female assistants. Long and strong
pins should also be held in readiness, with which to pin the binder
or bandage, after the delivery ; but it will often be found that the
female has a binder already made, which requires to be fastened
and retained with a cord, like a corset, but these are generally
troublesome and in the way, and I do not like them as well as
a good stout towel, or piece of unbleached muslin, about a foot
wide, and three or four feet long.

The room must be kept comfortably cool, and free from unpleas-

MANAGEMENT OF NATURAL LABOR.

267

ant odors, the clothing of the patient should be light and loose,
and the diet, if any is required, composed of crackers, gruel, toast-
water, tea, and cold water; no stimulating articles of food or
drink, nor meats should be allowed, nor should any solicitations
be used to induce an appetite.

Everything having been thus attended to and prepared, nothing
else can be done than to wait patiently for the second stage of
labor ; the practitioner can do nothing to facilitate the progress
of the first stage, and any interference to dilate the os uteri, or
passages through which the child has to be expelled, or in any
other way to hasten the labor, is a mark of ignorance, and is
fraught with serious consequences. Even the too frequent repeti-
tion of the vaginal examination is improper; probably, another
examination may not be required for an hour or two, but this will
depend very much upon the increased strength and frequency of
the pains, as well as the capaciousness of the pelvis, and the yield-
ing character of the soft parts. It is proper to examine the hypo-
gastrium occasionally to be certain that the bladder does not
become distended with urine, and this may be done at the time of
the vaginal examinations ; during a protracted labor, an attention
to this circumstance is very important, that the catheter may be
used without delay, as soon as a necessity for it arises.

In reference to the condition of the bladder, the accoucheur
should always personally satisfy himself, for it often happens that
he will be told the urine passes freely, when, in fact, there is only
a mere dribbling of fluid upon the recurrence of each uterine con-
traction, and which may be the liquor amnii, or a portion of urine
forced out of 'the bladder in consequence of its contraction by the
abdominal muscles ; this latter circumstance is an indication that
the bladder contains a large amount of fluid, which requires an
artificial evacuation. In introducing the catheter, the index finger
of the left hand is to be passed between the labia majora, and
carried toward the vestibulum, at the lower part of which, jtisi
within the lower angle of the . pubic symphysis, the meatus
urinarius may be detected by a slight pressure of the finger upon
this part ; the point of the catheter should then be passed along
the inner surface of the finger, until it reaches the urethral orifice,
when a slight movement will cause it to enter. It should be passed
upward without force, until about three-fourths of it has entered,
being careful not to allow it to slip entirely into the bladder; some
small vessel must be in readiness to receive the urine as it passes.

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AMERICAN ECLECTIC OBSTETRICS.

When the pelvis is occupied by the head, a flat catheter will be
preferable to a round one, as it does not take up so much spacein the
antero-posterior diameter. Sometimes the introduction of the
instrument into the bladder will be facilitated by gently raising«the
head of the child, during the absence of uterine contraction.

Some time may elapse before the commencement of the second
stage of labor, and a few suggestions relative to the mode of
employing the time, may be of service, especially to the young
accoucheur. If the labor has just commenced, and everything is
found right on examination, there will be no necessity for tarrying
at the house ; the practitioner may return home, or visit other
patients, being careful not to allow his absence to exceed one hour,
as it may then become necessarj* to institute another vaginal
exploration. Much, however, will depend upon circumstances ; if
it be a first labor, it will not, probably, progress very rapidly ; if
previous labors have been rapid, too long an absence from the
patient is not advisable, and more especially when the os uteri is
dilated to nearly the size of half a dollar, or is very soft and
dilatable; for it must be remembered, that although it may have
required several hours to obtain the above degree of dilatation, the
remainder of the process may be effected in a very short time, and
labor be completed by only a few more pains. Should the
physician conclude to remain with the patient during the first
stage of labor, and which is the course usually pursued when the
visit is late at night, il is not proper that he should continue all the
time in the parturient chamber, as it may prevent his patient from
attending to the fecal and urinary discharges, the calls to one or
both of which are apt to be rather frequent. He should retire to
some other room, generally, if possible, so situated that he can
hear the cries of the female, and thus be able to determine the
progress of the labor, as well as the necessity for another exami-
nation. Or, if this can not be done, the room not being favorably
situated for the purpose, he will request the nurse to inform him,
from time to time, of the advance of the pains, their frequency
and strength. While thus absented in another room, he may
employ himself in reading, in conversation, etc., but should never
permit himself to become so far interested in whatever employ-
ment he adopts, as, for a moment, to forget his patient. Or, if
there is a probability that the labor may not require his immediate
attention for a few hours, he may lie down on a sofa or bed, and
enjoy a short sleep, until the nurse awakens him, at such time as

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269

he may have requested. If there is but one room occupied by the
family, as is frequently the case with the poorer classes, it will be
proper for him to leave it occasionally to take a peep at the stars,
or a glance at the weather, or to inhale a little fresh air, for the
purpose of relieving a little dullness of feeling, etc., remarking as
he goes out, that he will return in ten or twelve minutes; thus
giving the female an opportunity to attend to her evacuations.
These little attentions, and especially if performed with a degree
of delicacy, will always produce a favorable impression, which may
subsequently prove advantageous to the physician.

While in the room with the patient, it is always proper to speak
encouragingly to her, and endeavor to cheer her up, occasionally
assuring her when such is really the case, that everything is going
right. But, above all things, avoid that very reprehensible and
demoralizing practice, which is too common among some persons,
of indulging in filthy and obscene conversation; some individuals,
and among them I regret to say are found females, seem to select
this as the best time for the delivery of all the obscenity with
which their minds are filled, and vie with each other as to who
shall bear off the palm in such disgusting, loquaciousness. This
kind of chat has a depressing and injurious influence upon the
patient, beside polluting the minds of all present; and I have no
doubt, but that the first approach toward a departure from virtue,
has, with many females, commenced in the parturient room, where
these coarse and indelicate conversations were permitted. No
gentleman, and certainly no lady, would be guilty of such low and
undignified behavior. It is the duty of the physician, at al
times, and under all circumstances, not only to preserve and
protect the health of his patient, but likewise to preserve and
protect the purity of her mind, and any one who pursues a
different course, should not be recognized as a professional brother
nor as a man worthy the confidence of community.

It is not necessary, during the first stage of labor, that the
female should retain the recumbent position, she may sit up,
walk about, lie down, and change her position, according to her
inclination; nor should any bearing down efforts be permitted
during this stage, as they exhaust the patient's strength, without
effecting the least benefit whatever, and may also cause a prema-
ture rupture of the membranes, and thus convert the labor into a
difficult one. It is only when the os uteri is fully dilated, and the
membranes have ruptured, Hhat she must assume the recumbent

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position, or make use of any voluntary efforts at bearing down.

After the full dilatation of the os uteri, until the birth of the
child, the female should be required to remain in the recumbent
position, lest, while moving about, the child should suddenly be
expelled upon the floor, and the uterus, following the cord and
placenta, become inverted. If, at the complete dilatation of the
os uteri, the membranes have not ruptured, the head 'presenting,
and the soft parts being yielding, the accoucheur should rupture
them ; but not under other circumstances, except those referred
to hereafter. Sometimes, the head emerges from the vulva
simultaneously with the rupture of the membranes, but this
most commonly occurs in cases where the membranes are
unusually tough, and have been allowed to remain entire until
the head has cleared the os uteri and advanced considerably into
the pelvic cavity.

During the second stage of labor, many practitioners .pass a towel
around each fore-arm, without removing the coat, as a protection
against the discharges. The towel is doubled so as to form a
triangle, the base, or folded edge of which, is passed rather
tightly around the wrist, but not so as to interfere with its free
motion, the rest being folded with one end over the other,
around the arm, and then pinned, and which is usually done by some
female present. Others, again, have oil-silk sleeves for the purpose
which they draw on over the coat sleeves. Some, merely
remove the coat, and roll up the shirt sleeves, thus having a free,
unimpeded use of the hand and arms, especially in cases where
manual assistance is required. This latter plan is the one which
I prefer ; but the accoucheur may please himself in these respects.

After the rupture of the membranes, the practitioner should
make no delay in ascertaining the -position of the presentation; and
an early examination, at this time, is often of much importance, as
any mal-position may be more readily rectified than at a later
period. The situation of the head at the time of the rupture
varies; most commonly it will be found just within the brim,
sometimes midway in the pelvic cavity, or at the perineum, etc.
The position of»the head may be determined by the rules named in
Chapter XXYI. During this stage of labor, the patient should
not be left by her medical attendant, who will find it necessary to
repeat his examinations every four, six, or eight pains, according
to their frequency and strength, and the rapidity with which the
head advances ; and after these examinations, it is not necessary

MANAGEMENT OF NATURAL LABOR.

271

to wash the hands each time, but merely to dry them on a napkin,
secured for the purpose. Should the patient suffer from cramps
of the lower extremities, they may be removed by frictions with
the hand over the part affected, or ligatures around it, or warm
applications ; pain in the sacrum, occasioned by pressure of the
presenting part upon the anterior sacral nerves, may be relieved
by firm, counter-pressure against the posterior face of the sacrum,
during a pain, and which should be made by the nurse, or some
female present; the practitioner should avoid any fatiguing
exercise, or manipulation, unless when imperatively required. If,
however, the pain should be very severe, and no relief be afforded by
the counter-pressure, and the efficiency of the pains be, at the same
time, diminished, it may become necessary to relieve the agony of
the patient, by hastening the delivery with the forceps. I have
heard of a Professor of Obstetrics, who informed his class, that he
had relieved several instances of this kind, by placing a folded
handkerchief between the head and the nerves. But it must be
remembered, that this would still further diminish the diameter of
the pelvic cavity, and be very apt to produce irritation, dryness,
and probable inflammation of the parts; perhaps the Professor
may have dreamed of these several cases, and forgotten that they
were but dreams.

The position which I prefer for the delivery, is on the back,
having the knees flexed toward the abdomen, and the feet resting
against some support, as the footboard of the bed ; and a sheet or
towel, fastened to the bedpost, may be held by the patient, upon
which she may pull during the presence of the pain, or the hand of
an attendant may be used. In this stage, the auxiliary aid of the
diaphragm and abdominal muscles are useful, and the patient may
be advised to make bearing down efforts, when the pain is on.
Her dress should be so far drawn up underneath her, as to prevent
it from being soiled by the discharges. And until the period when
the head presses upon the perineum, it is not necessary for her to
remain in one position all the time, though she must not be
allowed to get out of the bed. It is during this stage, that many
practitioners apply an obstetrical supporter with advantage ; the
description, in the note below, refers to Finch & Blaisdell's obstet-
rical supporter.* As a general thing, supporters have not been

*"The supporter consists, essentially, of a pad, to be placed upon the loins, and
upper portion of the sacrum, or where the patient desires pressure, when in labor. To
this, are attached straps that buckle in front of the shoulders, and prevent its falling, or

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found so useful in practice as was at first supposed, and are seldom,
if ever, made use of by the obstetrician.

Various other positions for delivery, are recommended by writers,
and assumed by females ; as sitting, kneeling, leaning over a chair,
and lying on the left side. Females, generally, will assume the
position recommended by the physician, but where they obstinately
prefer a certain position, and it is immaterial, as far as the delivery
is concerned, it is better to allow them their own way. Lying upon
the left side, with the knees flexed, and a pillow placed between
them, is the position most generally recommended in this country

slipping too low down upon the hips. At each end of this back pad, are rings, through
which pass straps terminating in a loop through which the feet pass, and are supported
as in a stirrup. At about as low as the knee, in these straps, are rings, through which
other straps are buckled, for the hands to grasp to give support to them.

"The part of the apparatus above described, when in use, acts as follows: When the
pains of labor are felt, the patient is inclined to push with her feet, and draw with her
hands; and let her position be either the recumbent upon her side, or her back, or the
sitting, either upon a chair, or the edge of a bed, the pressure upon the loop of the strap
with her feet, brings the back pad fh-mly against the place where her back requires sup-
port, and without the aid of an assistant, the back, the feet, and the hands, are at once
supported as long as the pain continues. As that passes away, the muscles of the
patient are relaxed, and she is at once relieved of the pressure, until the return of
another pain.

"The more prominent advantages of this part of the apparatus are, entire and certain
support for the hands, feet and back, in whatever position the patient may be, when
the pains come on, and an entire freedom from pressure when the pain ceases; and
the relief it gives to the attendant women, who are not called upon for the usual severe
physical efforts they are required to make when the supporter is not used. Another
great advantage is derived from its use in hot weather, as then the patient is not sur-
rounded with attendants whose breath and presence usually add greatly to her heat
and discomfort. With the supporter she needs but one person, beside the physician,
and she only to fan her, give her drinks, etc.; while without it, she would perhaps give
employ to two or three, who must be constantly near her.

"In addition to the above, there is an abdominal pad, which is so arranged, that it
can be applied to the lower part of the abdomen, where the child is too low to elevate
it to its proper position, or directly in front, or to the upper part of the abdominal pro-
tuberance if a downward pressure is desired. This can be drawn as firmly against the
abdomen as may be desired, and either fastened thus, or attached to the straps which
support the feet, so that additional pressure will be given by the feet at each pain.
With all these advantages, the woman is not confined so but she has the perfect use of
her limbs, and can lie down, sit, stand or walk, as well while wearing the supporter, as
she otherwise cpuld do.

"During the present week, I was called to attend a young woman in labor with her
second child. She is a large, muscular woman, and capable of great physical effort.
Some months since, she felt a pain in the lower part of the abdomen, just above the sym-
physis pubis, and the pain and tenderness continued to increase up to the day of confine-
ment. There was nothing unusual about the labor, at first, except the pains were quite

MANAGEMENT OF NATURAL LABOR. f 273

and England ; but I do not think that the delivery proceeds with so
much ease and rapidity as when the female is placed upon the back.
Some writers maintain, that the action of the uterus is frequently
interfered with, and the progress of labor impeded, when the female
lies on her left side, in consequence of an obliquity of the uterus,
caused by this position ; also, that the too close condition of the
limbs, produced thereby, retards the labor, and to overcome which
the advocates of this position, advise a pillow to be placed between
them, which causes much unnecessary heat. When lying upon the
back, the limbs can be kept apart with ease, the axis of the uterus
is brought into a favorable direction for an easy delivery, and the
patient, being in a position requiring no muscular exertion to main-
tain, can freely and more powerfully employ the abdominal muscles.

When the head has reached the perineum, the practitioner will
take his seat, by the bedside, in the position heretofore named, and
as the part begins to distend, he should keep his finger gently upon
the head, during each pain, so as to ascertain the proper period for
supporting the perineum, in order to protect it from becoming
lacerated, and the advance of the head must be determined, not by
its condition at the pubic arch, but at the perineum. As soon as
the perineum is fully distended and protruding, and the head about
emerging, and not before, a folded cloth, or napkin, is to be placed
over it, extending from its anterior edge to the coccyx, and which
must be supported by either hand, as the case may require, but

hard, and the distress was mostly felt at the old seat of tenderness. As the head of the
child descended to the lower pelvic strait, the membranes gave way, and the amniotic
fluid was discharged, and immediately the patient complained of severe tearing pains in
front. After two or three additional pains, and after the discharge of all the water, she
said the distress in that region was beyond endurance. On passing my hand over the
abdomen externally, I found that part, where the pain had been felt, very tender, and
protruding a globular tumor of the size of a two-quart measure. Fearing a rupture of
the uterus, I applied the abdominal pad of the supporter firmly over the protrusion, and
proceeded at once to extract the child with the forceps. From appearances at that time,
and subsequently, there was no doubt in the minds of those present, or in the mind of a
physician who examined the case a few hours afterward, that the only thing which could
be done to prevent a rupture of the uterus, was the timely application of the abdominal
pad, and the extraction of the fetus. From the time when the protrusion occurred,
until the woman was delivered, could not have been more than three minutes; but
during that short space, she says, she suffered more from the peculiar pain she felt in
front, than from all the pains of her former and present labors combined.

"In ordinary easy labors, it may not be desirable, in all cases, to apply the supporter;
but in hot weather, in all protracted, or severe cases, and especially in those cases where
the back or the abdomen require unusual support, I think this apparatus will give
entire satisfaction to all who make a trial of it." — Boston Med. and Surg. Journal.

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commonly the right. The pressure made must be moderate, it must
not interfere with the advance of the head, the part requiring firmer
support toward the coccyx than at its anterior edge; and instead of
making efforts to retract the skin over the head, as it passes through
the orifice, it should be rather carried forward, which will diminish
the risk of laceration, by facilitating the movement of extension of
the fetal head. This pressure should only be made when the pain is
present, and it would be much better to leave the part entirely
untouched, than to make improper pressure, which has frequently,
of itself, occasioned the very difficult}' it was intended to obviate.

My experience in this matter, leads me to believe, that laceration
of the perineum would be a rare accident, were the rule to support
it during the latter part of the second stage, entirely dispensed
with in obstetrical practice. Some writers recommend the support
of the perineum, not only during the passage of the head, but
likewise of that of the shoulders, from a belief that the perineum
is frequently lacerated as the bis-acromial diameter is emerging;
in some instances, an attention to this point may prove serviceable,
but I do not regard it necessary as a general rule.

"While the head is at the perineum, pressing upon the lower part
of the rectum, a great disposition to evacuate the bowels will be
produced, and the female will desire to rise and attend to the call ;
but it must by no means be granted, as a violent pain might come
on, and the child be delivered, and perhaps, destroyed, before the
physician could bestow the necessary attention. Beside, these
desires generally disappear with the delivery of the head. I have
twice witnessed the delivery of the child, and its reception into the
chamber-utensil, where the physicians had permitted the females to
attempt an evacuation of the rectum, at this stage of the labor.
Again : should the bowels not have been opened, early in the labor,
and the probability is, that a fecal discharge may happen, the
patient must not be permitted to rise from the bed, but must per-
form the evacuation on some old, useless cloths, to be placed under
her for such purpose, and which are then to be immediately
removed.

It is sometimes the case, that the pains cease, or diminish in
strength, toward the close of the second stage, but they may be
renewed by making firm pressure with the left hand, upon the ute-
rus, each time of its contracting, or, by pressing firmly on the end
of the sacrum.

As the head passes through the vaginal orifice, it should be

MANAGEMENT OF NATURAL LABOR.

275

received into the right hand, holding it loosely, so as to admit of
the motion of restitution, and, at the same time, a finger should be
passed around the neck of the child to ascertain whether the umbil-
ical cord is coiled around it, and which commonly occurs when the
cord is of more than ordinary length. If the neck be embraced
by one or more turns of the cord, it must be liberated by loosening
it, and passing it over the head ; or else the following results may
ensue, especially if the cord be short : the compression may arrest
the circulation in the bloodvessels of the neck, and prevent the
access of air into the lungs by closure of the trachea, thus destroy-
ing the child ; or, the expulsion of the child by a strong pain,
might cause inversion of the womb, or serious hemorrhage by tear-
ing the placenta from its uterine attachment. If the cord can not
be easily passed over the head, it must be loosened as much as pos-
sible, so as to prevent strangulation of the vessels of the neck; for
it must be remembered, that ordinarily, even with two or three
coils around the neck, the cord will be sufficiently long for delivery
to take place, without any evil consequences to the mother.
Sometimes, the cord is so placed around the neck, that it has to be
divided before the body can be born, a ligature being applied as
soon as possible ; but this is done only in those extremely rare
cases, where the free portion of the cord is rendered so short as to
endanger inversion, should the child be delivered. It is frequently
the case, that an evacuation of the rectum occurs with the expul-
sion of the head, but the compress at the perineum serves to pro-
tect the hand of the accoucheur from being soiled by it.

As soon as the head is born, the child commonly commences
crying lustily ; frequently, however, the presence of mucus inter-
feres with its breathing, and the practitioner should pass a finger
into its mouth for the purpose of removing any mucus or other
obstruction that may exist there.

No attempt, whatever, should be made at removing the body,
unless much delay occurs in the natural process, or the life of
the child is in danger. After the birth of the head a short inter-
val generally follows, but if this is prolonged, serious consequences
may result ; under such circumstances, a finger may be inserted
into the axilla nearest the perineum, and traction made in the
direction of the axis of the inferior strait, while, at the same time,
pressure is to be made by the other hand, or by an assistant, on
the abdomen over the uterus. One shoulder disengaged, the
other follows, and the child is born without any further trouble.

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AMERICAN ECLECTIC OBSTETRICS.

But, when the body follows the head without requiring any assist-
ance to expel it, the right hand must be passed along with the
head, supporting it as it moves, and the body must be supported
by the left hand ; and as soon as the child is expelled, it should be
laid upon its right side with its back to the mother's genitals, to
prevent it from receiving any of the copious discharge which
follows, into its mouth; or it may be placed with its abdomen
toward the mother, so that the mouth is protected from the dis-
charges. And in moving the child, care must be taken not to
make sudden or powerful traction on the cord, as the uterus may
become thereby inverted, or a portion of the placenta by being
roughly detached, may occasion alarming hemorrhage.

The expulsion of the child terminates the second stage of labor;
and it must be ever borne in mind by the physician, that in a case
of natural delivery, there is nothing for him to do in these two
stages, but witness the progress of the labor, console and encourage
his patient, and receive the child after its expulsion. Any inter-
ference, in either the first or second stages, when everything is
proceeding favorably, further than I have just described, is exceed-
ingly improper and criminal.

I am aware that some writers advise, and many practitioners
adopt the plan of administering ergot to all parturient women, in
the second stage of la*bor, for the purpose as they say, of pro-
moting the easy expulsion of the placenta, and subsequent uterine
contraction, thereby lessening the risk of hemorrhage; but, more
for the purpose, as I strongly fear, that they may the sooner visit
another patient and procure another fee, or, perhaps, from want of
sympathy and patience. I consider this a very unscientific and
censurable practice, and have witnessed many accidents resulting
from it ; indeed, when the action of the ergot has subsided, the
reaction that must ensue, would be very apt to produce a condition
of the uterine tissue favorable to hemorrhage from that organ.
From a practice'and observation of twenty years, I am thoroughly
convinced, that the administration of ergot to cause contractions
of the uterus, whether indicated or not, occasions and develops a
greater proportion of diseases of the organ, than is generally
suspected by the profession.

A natural labor may be accomplished in two hours, or it may
continue for twenty-four or even longer, without any danger.
The danger is never to be estimated by the time which the process
occupies, nor by the severity of the pains, but by the symptoms

MANAGEMENT OF NATURAL LABOR.

277

which are present. So long as the parts are in a proper condition,
position and presentation right, and the pulse unaffected, there is
no necessity for haste, alarm, or officious intermeddling, no matter
how long the labor continues; the practitioner should appear
cheerful, resolute, and confident, at once check any complaints or
whisperings among the female attendants, and use all means to
sustain the patient's spirits, and preserve her from a despondency,
which may cause a suspension of uterine contraction, and convert
the labor into a difficult one. But, if the parts become hot and
dry, with more or less tenderness on being touched, and the pulse
accelerated, it is then necessary to interfere, calmly, deliberately,
without violence or rudeness, and employ the proper means to
overcome the difficulty.

Sometimes, after the delivery of the child, the female will be
attacked with violent pains, and forcible straining, or bearing-down
efforts ; as these may be owing to a disposition to inversion of the
uterus, the practitioner should endeavor to ascertain their cause,
and remove it if possible, at the same time urging upon the female
the importance of resisting these efforts as much as possible, lest
inversion should be produced by them.

The third stage of labor commences after the birth of the child,
and may be considered the most important period of the process,
for by far the greater part of the accidents of labor occur at this
time, either from improper intermeddling, or from an ignorance of
the correct mode of proceeding. After having observed that the
child is living, as made known by its crying, it must be separated
from its uterine attachment ; and this must be effected without any
exposure of the mother — a point which I desire the reader
especially to impretp upon his mind — as many practitioners, at this
stage, are very apt to needlessly expose their patients.

As soon as the pulsation of the cord of the living child ceases
toward its placental extremity, say at a distance of five or six
inches beyond its abdomen, or, as far as can be reached by the hand
without introducing it into the vagina, the accoucheur will proceed
to cut the cord. The child must be withdrawn from beneath the
bedclothes, if the length of the cord will permit : or if too short,
the operation must be performed under the bedclothes, raising
them to effect it, taking especial care, however, to previously place
over the parts of the patient a well-aired cloth or towel, that they
be perfectly covered and concealed.

The ligatures, which had been prepared in the early part of the

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AMERICAN ECLECTIC OBSTETRICS.

labor, are now to be used ; they should not be so thin as to risk
cutting through the membranes and vessels of the cord, nor so
thick as to be incapable of making firm compression, sufficient to
prevent bleeding after the separation. The cord is to be tied
tightly with one of these, at a distance of an inch or an inch and
a half from the umbilicus, care being had not to include any
portion of protruding intestine, which is occasionally met with ; as
in these cases, the incautious ligaturing of the intestinal protrusion
would give rise to the most disastrous consequences.. The second ,
ligature is to be applied two or three inches beyond the first, and
the division must be made between the two with the scissors, being
careful not to excise, at the same time, a finger, or a portion of the
child's penis, if it be a male. In this operation the practitioner
should see what he is doing. I am well aware that many authors
advise the application of but one ligature, and consider the employ-
ment of the second superfluous, but I prefer two in all cases, not
from an erroneous impression held by some, that the female may lose
blood through the unprotected, open vessels of the cord, but for the
following reasons : In the first place, I am well convinced, that, in
many instances, by thus retaining the blood within the cord and
placenta, it acts as a provocative to uterine contraction and insures
a speedy detachment and expulsion of the placenta; secondly, it is
much more cleanly, and dispenses with the pressure of the thumb
and finger to prevent the blood from spurting over the bedclothes,
or even on the clothing of the practitioner ; thirdly, it is safe in case
of twins, with anastomosed circulation in the placenta, should the
practitioner, as is frequently the case, have neglected to place his
hand on the abdomen to ascertain the size of the uterine tumor, and
the probability of the presence of a second child ; and fourthly,
should it be judged advisable not to have the second ligature, it can
very readily be removed, or another separation of the cord be made.

It is sometimes the case that the child is born in a state of defec- *
tive vitality, asphyxia, or apoplexy. If the pulsation in the cord
continues, and the child does not breathe, some cold brandy
sprinkled on the region of the diaphragm, and perhaps a few light
frictions made rapidly over the body and extremities with a piece of
warm flannel, will be all the means required for its resuscitation ;
previous to which, however, the finger must be passed carefully into
the mouth, as far down as possible, in order to remove any mucus
which may be present, obstructing the respiration.

Where these means do not suffice, it may become necessary to

MANAGEMENT OF NATURAL LABOR.

279

produce artificial respiration ; a flexible catheter, or laryngeal tube
must be cautiously and correctly introduced into the larynx, after
which the angles of the mouth must be closed to prevent the escape
of air ; the practitioner will then apply his mouth to the free end
of the tube and slowly and gently inflate the lungs, simulating
breathing by making gradual pressure on the chest to expel the air,
which he continues to introduce for some time ; with these attempts
he may also sprinkle water or brandy over the face and chest, apply
warm flannel to the surface and administer an injection. Some
children are not resuscitated until after a persevering trial of an
hour or two. The first symptom of returning life is a short sob,
which increases in frequency until respiration is established, after
which, the child should be kept at a sufficiently elevated tempera-
ture, and in a state of rest and quiet. Upon the first return of
vitality, the warm bath used for a very short time, frequently
facilitates the restoration.

This condition of the child may arise from a premature detach-
ment of the placenta, from uterine hemorrhage, or from defective
nourishment, and is generally accompanied" with little or no
pulsation in the cord, and but slight action of the heart, and as
nothing is to be gained by maintaining the connection of the
fetus with the uterus, it will be proper to cut the cord ; but in all
instances where the pulsation of the cord is distinct, though feeble,
I deem it inadvisable to make the division, until respiration has
been fully established ; and in those cases where the placenta has
been expelled, it should be wrapped in warm, damp cloths, and no
separation made until all pulsation in the cord ceases.

Apoplexy may be known by the lividity of the face, blueness of
the surface, labored, or obscure action of the heart, and feeble, or
imperceptible pulsation in the cord; while, in the instances above
referred to, the color of the surface is natural, or pale. Apoplexy
may result from prolonged labor, compression of the head by a
narrow pelvis, or from a delay in the expulsion of the body after the
delivery of the head, etc., and it must be treated by removing the
cerebral and pulmonary engorgement. In these cases it is recom-
mended to cut the cord witmSut ligaturing it, and allow the escape
of from half an ounce to an ounce of blood, at the same time
sprinkling tepid water over the head, face, and chest. As in the
previous instances, the mouth and fauces should be freed from
mucus, and artificial respiration may be attempted. If recovery
ensues, the surface becomes paler, or slightly rosy, the pulse more

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frequent and stronger, and efforts at inspiration are made ; and
when these symptoms appear, the cord may be tied. In all these
instances, the practitioner should not become discouraged at too
early a period, and therefrom slacken his efforts, as almost hopeless
cases have been resuscitated after long, but patient and continued
treatment. When the pulsations in the heart and cord have ceased
for several minutes, attempts at restoration will be useless.

The cord having been cut, the child is to be passed to the nurse,
who is generally ready to receive it in a small blanket, prepared
for the purpose; but as its body is very slippery with the waters,
blood, or vernix caseosa, there may be danger of dropping it, if it
be not taken hold of properly. To avoid any such mortifying
accident, the practitioner will seize it by the ankles, with his left
hand, placing a finger between the two ; and will have the back of
its neck to rest in the arch formed by the thumb and index finger
of his right hand, resting the upper portion of its back upon the
palm of this hand, and placing the points of the three remaining
fingers under its right axilla ; thus held, it can not fall. Some
advise the left hand to be placed at the breech, with one finger
between the legs, the left thigh grasped by the thumb, and the
right thigh and nates resting on the remaining fingers and palms
at the same time making gentle pressure of the hands toward each
other, for the purpose of more firmly securing the child. Either
of these methods may be safely adopted.

The next thing is to ascertain, if it has not been previously done
whether there is another child in the uterus ; this may be known
by placing the hand on the abdomen, when the fundus uteri will
be felt still in the epigastric region ; and an examination per vagi-
nam will detect the bag of membranes, and the presenting part.
If, however, the uterus be found small and hard like a solid ball,
when grasped through the abdomen ; or small, but soft and
doughy ; or small, but becoming hard and soft alternately, no sec-
ond child is present, and the placenta has probably passed, either
partly or wholly into the vagina. If it be hard and nearly the size
of the adult head, there is no child, but a contraction of the uterus,
upon the mass inclosed within its cavity ; and if it be thus large,
but soft and doughy, contraction of the organ has not yet taken
place for the purpose of expelling the placenta. The treatment of
twin cases will be considered hereafter. Having ascertained that
no twin-child is present, the practitioner will attend to the delivery
of the placenta; occasionally, the same pain which expelled the

MANAGEMENT OF NATURAL LABOR.

child likewise ejects the placenta. But, usually, from five to thirty
minutes elapse from the birth of the infant, before the uterine con-
tractions are renewed for the purpose of removing the secunclines.
The left hand should be placed on the hypogastrium, and if the
uterus be found hard and well defined, and the patient complains
of some pain, but not so severe as before, the organ is contracting
and expelling its contents, and the right hand should be ready to
receive them as they emerge. If, however, the uterus be found
large, soft, and yielding, or, if it be not felt at all, it may be caused
to contract by gentle friction and pressure on it, through the abdo-
minal parietes, and as soon as it contracts, the woman should bear
down, and slight traction be made upon the cord with the right
hand, in the direction of the axis of the superior strait, which will
carry the cord backward to the os coccyx, and as soon as the pla-
centa moves, the motion will be recognized by the hand. In the
meantime,_the left hand should continue upon the hypogastrium,
both for the purpose of exciting the contractions, as well as to
admonish a cessation of the traction, whenever the uterus grows
soft, or manifests a tendency at some portions of the fundus, to
become depressed and follow the direction of the traction, and
thus, probably, be partially or completely inverted. Whether the
placenta be in the uterus or vagina, if the soft condition of the
uterus continues, notwithstanding the means used, the labor may
be complicated with hemorrhage, to treat which, according to the
rules hereafter given, the physician must be thoroughly prepared.

When the placenta has emerged from the vulva, it should be
twisted or turned around several times, for the purpose of forming
a cord or string of the membranes, that, thereby, no portion of
them be left attached to the uterine surface, thus effecting a clean
and perfect delivery. If a portion of the membranes be left within
the uterine cavity, they may give rise to unpleasant symptoms, as
putrefaction, offensive discharges, etc.; or should portions of them
pass away in a few hours afterward, they may occasion alarm to
the patient, or lead her to think that her medical attendant is not
perfect in this department of his profession.

It is always proper for the practitioner to ascertain as early as
possible after the birth of the child, whether the placenta is de-
tached, that he may remove it ; but, unless there be flooding, or
some other circumstance demanding the immediate delivery of it,
it is inadvisable for him to make any more active efforts than
above named, to bring about its expulsion when not effected natu-
19

282

AMERICAN ECLECTIC OBSTETRICS.

rally, for at least one hour subsequent to the child's egress; then
he will treat it as a retained placenta. And in all cases of natural
labor, it must be thoroughly impressed upon the mind, that no
force or haste is required in removing the placenta and membranes,
but they should be drawn forth slowly and carefully, to prevent
any tearing of the membranes, or other unpleasant accidents
arising from too hasty a removal of them from the uterine or vagi-
nal cavity.

The secundines being completely removed, the practitioner will
request the nurse to bring a basin or some other vessel, in which
to place them, covering them with a cloth, "for the sake of
decency." Then he will ascertain, by placing a hand on the abdo-
men, whether the uterus is small and contracted, or large and soft,
which latter condition indicates a tendency to internal hemorrhage,
and the pul^e and countenance of the patient should be at once
examined, as described hereafter. The delivery of the placenta
closes the third stage of labor ; a stage of the process which
requires much judgment and presence of mind, for the slightest mis-
take or misconduct might lead to the most serious consequences ;
and with all difficulties which may occur at this stage, as well
as their treatment, the physician should be thoroughly and famil-
iarly conversant.

As soon as possible after the birth of the placenta, and especially
in cases where it has been found necessary to extract it artificially,
the practitioner should ascertain that there is no inversion of the
uterus, and should likewise examine the placenta and membranes
to see that the whole of them have passed away, and that no portion
of them has been left within tbe uterine cavity, subjecting the
patient to severe pains, nausea, vomiting, and hemorrhage. In this
examination both surfaces of the placenta should be inspected.

Unless there are certain circumstances, or symptoms present,
which will be referred to hereafter, it is not material that the
bandage or binder should be applied until after the expulsion of the
placenta. It should be passed under the patient's back, carefully,
being made to embrace the hips and the whole abdomen, and with-
out requiring any efforts on her part to assist in its application ; it
should be pinned or fastened from below upward, having that por-
tion around the hips and lower part of the abdomen, more tightly
applied than the rest, or sufficiently tight to occasion a very slight
degree of uneasiness when first placed on. If, however, there should

MANAGEMENT OF NATURAL LABOR.

283

be considerable of the discharges present, so as to endanger wetting
the binder, these must first be removed, or covered over with dry
cloths. Many writers consider the bandage of no practical import-
ance, but I am well convinced of its utility. When firmly applied,
and pressing equally upon the anterior surface of the abdomen, it
promotes the regular contraction of the uterus, and gives support
to the viscera, thereby diminishing the risk of hemorrhage, and
syncope ; it likewise assists a return to the natural condition of the
abdominal parietes, preventing that lax state of the integuments
which causes a " pendulous belly." When, in dropsy of the
abdomen, the sudden removal of the pressure is effected b}^ tapping,
unless a bandage is applied and tightened as the water passes off,
syncope and nausea are very apt to ensue; the removal of the
uterine contents in labor, whereby a removal of pressure is speedily
accomplished, is a somewhat analogous case, requiring similaj
measures for relief. The binder may be worn for a few days sue
ceeding delivery, not certainly to exceed eight or nine; and its
longer employment, as advised by some physicians, for two or three
weeks, strikes me as being a useless measure. A bandage applied
too tightly, and especially when worn longer than the first few days,
would, in my estimation, very much endanger some displacement
of the uterus. Generally, the binder is applied by the nurse or
some female friend, but the physician should understand how to
apply it himself, and should always ascertain that it is properly
placed and tightened before leaving the patient. He will, frequently,
be requested to place the bandage on his patient, but, as a general
rule, I consider it a task entirely out of his province, and one which
should be invariably performed by a female. To be of the greatest
service, the bandage should be applied next the skin, and I can not
conceive of any office more offensive to female purity and modesty,
and more repugnant to the sensitiveness of a man of honor and
refinement, than that of bandaging a naked and exposed parturient
woman. True, physicians and females have often to be placed in
even more delicate and exposed situations than this, but then it is
only in those cases in which health and life render it imperatively
necessary, and in which, from the dangers to the patient, modesty
becomes a vice. She must be, truly, an ignorant nurse, who is inca-
pable of correctly bandaging a parturient female. Although I
consider the application of the bandage, the duty of the nurse, yet
it is the physician's duty to ascertain, after it has been done and the
female covered, whether it is applied properly. And in those

284

AMERICAN ECLECTIC OBSTETRICS.

instances where he is *desired to place the bandage, himself, and no
excuses will be received, he may adjust it over the body-garment of
the patient, and thus obviate the necessity for exposure. After the
application of the binder, some warm, dry cloths should be loosely
applied to the vulva, for the purpose of absorbing the discharges,
and preventing them from soiling the dry clothes of the patient.
These cloths should be examined from time to time, while in the
house, for the purpose of ascertaining the degree of hemorrhage ;
and for the same purpose, the hand may be placed upon the abdo-
men occasionally, to learn if the uterus continues contracted; the
pulse likewise ought to be felt several times, and inquiries be made
as to whether the patient experiences any sensations of faintness.

The " putting to bed," as it is termed, in which the patient is
moved into her regular bed, should take place as soon as circum-
stances will permit ; in ordinary labors it may be accomplished in
an hour after the delivery, or, following the washing and dressing
of the child ; but if the labor has been tedious, or very painful, it
must be delayed according to the strength and circumstances of the
patient. In the process of " putting to bed " the practitioner must
be very careful that the patient uses no exertions on her part for
the purpose of giving assistance, and that she be not removed from
the horizontal position, lest hemorrhage be thereby induced. The
husband and two females may carefully raise and remove her, or she
may be carried in a strong sheet, held by four persons ; it matters
not how the removal, or " putting to bed," is executed, so it is
with care, and an attention to the above points.

As soon as the mother can be safely left for a short time, and
the nurse's attention to her can be dispensed with, the child, which
had been warmly wrapped up and placed in some safe location,
must be attended to. It must be washed and dressed. This is
almost always the task of the nurse, or some female present ; yet
the practitioner should understand how it is to be done, in case
inquiry be made of him, or he should be left in a condition where
he would be required to act the part of nurse ; a part, however, to
which I most decidedly object, except in imperative cases.

The body and limbs should be lubricated with Sweet Oil, fresh
Lard, or fresh Butter, which will assist in the more ready removal
of the sebaceous matter with which the skin of the child is cov-
ered at birth; after which, warm soap-suds will be the only applica-
tion required. If the above substance is not thoroughly cleansed
from the the skin, it may occasion painful and troublesome cuta-

MANAGEMENT OF NATURAL LABOR.

235

neous excoriations. Be careful that, in washing and drying, the
tenderness and integrity of the infant's skin be regarded, as too
much pressure, or too much friction may bruise or abrade it ; soft
cotton, or linen should be used^both in the washing and drying.
Some apply cold water to the infant, but this is wrong, and fre-
quently injurious, requiring a very robust child to pass through
the ordeal with safety. The child has just emerged from a situa-
tion of an elevated temperature, and a reduction of this tempera-
ture too sudenly, or too soon after birth, would, especially in those
who are weak and delicate, be very apt to occasion serious and
even fatal consequences. In washing the child's head, many
nurses are accustomed to apply a small portion of warm spirits
of some kind, for the purpose, as they say, of preventing its taking
cold ; whether this acccomplishes the intention or not, there can
be no objection to the practice, if too great a quantity of liquor be
not employed.

After the washing, the accoucheur will be called upon to dress
the cord ; but previous to this, it will oe proper for him to exam-
ine the child, and ascertain that it is not malformed. Some exam-
ine for this purpose, even before its washing This having been
done, a piece of soft linen must be doubled, so as to form a square
whose sides measure six or seven inches; this is again doubled
and folded in a triangular form, somewhat in the manner of pre-
paring a paper filter, so that its point, which will be the center of
the square when opened, may be applied to the flame of a lamp or
candle, to form an opening of sufficient size, through which to
pass the cord. I prefer making the orifice by burning instead of
cutting, as its edges are thereby much softer and less liable to
increase any existing irritation of the parts in contact with it. This
is then opened, and through the orifice thus formed in the piece of
linen, doubled, the cord is to be passed. The linen may now be
allowed to lie upon the abdomen, and another piece placed over it
and the cord, or the cord may be wrapped up in the first piece. But
whichever plan is adopted, the cord must be placed upward along
the abdomen, rather to the left, in order to avoid any compression
of the liver, and secured in this position by a bellyband or bandage,
passed, but not too tightly, around the child's body. If any blood
be found to ooze from the end of the cord previous to dressing it,
another ligature must be applied nearer the umbilicus. The
remaining piece of the funis umbilicalis dries up, and usually falls
off in five or six days, though this may vary from two to sixteen

28b AMERICAN ECLECTIC OBSTETRICS.

days. It is not, commonly, necessary for the practitioner to exam-
ine the cord at subsequent visits, for every time the nurse bathes
the child, she makes it a matter of duty to inspect its condition
herself, and from her any information relative to it, under ordi-
nary circumstances, can he obtained. After the application of the
bandage, the child should be lightly and loosely dressed, accord-
ing to the season, and all cumbersome and tight clothes placed
aside, as injurious to its health and welfare.

The child should be placed to the breast as soon as possible, for,
in many instances, it will at once obtain a suppty of the mother's
milk ; but should it fail to suck, or should no milk have been
secreted, there will be no necessity for feeding it until several
hours have elapsed. Some recommend it to be kept from the
breast for ten or twelve hours ; this may answer in cases where there
is much exhaustion, or where the labor has been protracted ; but
in ordinary instances I prefer placing it to the breast as early as
possible. Should it become advisable to feed the child, a little
warm milk and water, without sweetening, or some thin gruel, will
be the only food required ; but after it obtains the mothers milk,
no other food, whatever, should be allowed.

The substance collected in the intestines of the fetus, during
utero-gestation, is called " meconium," and if it be not removed
soon after birth, it will occasion gripings, colic, etc. The first
breast-milk of the mother, secreted after delivery, is the best agent
for the removal of the meconium: it is called colostrum, and con-
tains, in addition to the common milk globules, numerous, large
cells, or granular corpuscles, whose investing membrane is tilled
with oil, or common milk globules, similar to those which are float-
ing free in the surrounding fluid. This colostrum appears to exert
a laxative influence on the child, and is superior to any other agent
for the above purpose ; if it can not be had within a few hours suc-
ceeding delivery, some Sweet Oil, or Castor Oil may be given, to effect
the evacuation. I do not believe in dosing an infant with medicine
as soon as it is born, for, owing to the customs and habits of society
it will become a charge to the physican soon enough, without
attempting medication from the moment of birth ; therefore, care
and prudence should be manifested in making use of laxatives to
purge off the meconium. And, above all things, for the sake of
decency and of science, forbid that nauseous, abominable, and worse
than heathenish practice, which some old nurses have, of forcing
down the child's throat, a disgusting mixture of urine and molasses.

MANAGEMENT OF NATUKAL LABOR. , 287

During these attentions to the child, the mother must by no
means be neglected ; her pulse should be examined from time to
time, and other investigations pursued to ascertain the condition
of the uterus, and whether any disposition to hemorrhage exists.
The practitioner should never leave the house for at least one hour
after the delivery of the placenta, and he who leaves earlier than
this, is criminally guilty of the loss of his patient, should she,
shortly after his leaving, die, from uterine hemorrhage. There is
no excuse for him. If it is absolutely necessary for him to leave
the house, previous to the termination of the hour, let him have
another physician called in, to temporarily supply his place. If
the labor has been a tedious one, or the patient is much exhausted,
or if the womb does not contract properly, the house should not
be left for even a longer period than an hour, depending, however,
upon the circumstances of the case.

When about to return home, the accoucheur should place his
hand upon the patient's abdomen, to learn whether the uterus is
small, hard and contracted ; he should examine the condition of the
pulse, and likewise request the nurse to show him the cloth which
had been placed at the vulva, that he may form some idea of the
quantity of blood discharged. He should direct a simple diet of
toast and tea, gruel, barley-water, and similar articles, and posi-
tively prohibit the admission of friends into the parturient room,
for a period of at least twenty-four hours ; the rooms must be kept
comfortably warm, and properly ventilated without exposure of
the patient, and perfectly free from auy noise or excitement. He
should leave the most positive orders that the female shall not
assist herself in anything, and especially that she continue in the
horizontal position, for even the momentary semi-erect posture has
frequently occasioned alarming hemorrhage ; and he should also
ascertain that the bandage is properly secured.

CHAPTER XXV.

ATTENTIONS REQUIRED SUBSEQUENT TO DELIVERY, DURING THE PUERPERAL STATE.

In about twelve hours the patient should be again visited by her
medical attendant, and even sooner than this, where the labor has
been tedious, or where there is a disposition to hemorrhage. As

288

AMERICAN ECLECTIC OBSTETRICS.

with the process of natural labor, so with the puerperal state, when
uninterrupted by accidents, no interference is required on the part
of the practitioner ; the patient will gradually attain her normal
condition, unaided ; yet as many females, who pass through their
labors with safety, perish in the subsequent puerperal condition
from inflammatory attacks, it is the duty of the attendant to
superintend this condition, that he may at once adopt the proper
measures to remove any abnormal symptoms that may arise.

The shock to the nervous system from labor, effects a derangement
varying from mere restlessness to absolute hysteria; in easy labors,
the patient soon recovers from it, requiring only a state of rest and
sleep. When severe, it is characterized by symptoms of exhaus-
tion, with an alteration in the appearance of the eye, an anxious
countenance, derangement of the brain, the sensibility of which is
either diminished or increased, and a disturbance of the circulating
and respiratory systems ,as manifested by the pulse, which is slow
and labored, or rapid and fluttering, or alternating from slow to
rapid, and which must not be mistaken for the pulse of peritonitis,
and also by the hurried, panting breathing.

The pulse will be found to increase during the second stage of
labor, to diminish after this is completed, and to rise again on the
secretion of the milk. A pulse ranging from 100 to 110 in the
puerperal state, should be watched, though it is not always indica-
tive of danger. A quick pulse may be present when a large clot
is in the uterus, it may occur with diarrhea, gastric disturbance, or
severe after-pains ; and when founcj immediately after delivery, it
frequently indicates hemorrhage. A quick, feeble, fluttering pulse
occurs in the collapse from the nervous shock. There is a sensa-
tion of fatigue experienced in the shoulders and in the muscles of
the abdomen, which sometimes persists for three or four days. It
is occasioned by the muscular efforts made during the second stage
of labor, and which may be discriminated from peritonitis, by the
pulse not being increased, by no aggravation of the pain on pres-
sure, and by the absence of febrile symptoms. When these
symptoms are not very severe, they will subside upon keeping the
patient quiet, and free from excitement, together with a few hours
sleep. If severe, small doses of the compound powder of Ipecac-
uanha and Opium may be administered with advantage, and to
each dose of which a grain or two of Caulophyllin may be added.
In some instances equal parts of Xanthoxylin, Caulophyllin, and
Scutellarin, may be mixed together, and given in three-grain doses

ATTENTIONS SUBSEQUENT TO DELIVERY.

289

every hour or two. The diet should be nutritious, the patient
kept quiet, prohibiting the visits of friends, and for a few days
nursing may be avoided. When symptoms of collapse or great
exhaustion are present, stimulants may be allowed, as a moderate
quantity of brandy and water, wine, or aqua ammonia, and these
may be given in conjunction with the compound powder of Ipecac-
uanha and Opium. The stimulants must be omitted as reaction
comes on, for if continued beyond this, they will be likely to pro-
duce mischief.

The vagina, notwithstanding its great distension, soon recovers
its normal size, and the heat and soreness speedily disappear,
unless the labor has been protracted during the second stage, or
the lochial discharge becomes acrid. The integuments of the abdo-
men do not so readily recover their natural condition ; they remain
loose and flaccid for a long time; but if the bandage be properly
applied, the only evidence of pregnancy which they afford, will
be the white streaks on the external surface of the abdomen, linear
albicantes. The contractions of the uterus after delivery, not only
reduce its size, but prevent uterine hemorrhage, remove all sub-
stances from within its cavity, and diminish the caliber of its ves-
sels and sinuses. The contraction, however, is not permanent, but
is followed, after a short time, by an interval of relaxation ; and
these alternate contractions and relaxations continue for eight or
ten days, during which time the organ can be felt and examined
through the relaxed walls of the abdomen, after which it becomes
so reduced in size as to descend into the pelvis, when it can no
longer be distinguished through the abdomen. A day or two after
delivery, the lining membrane of the internal cavity of the uterus,
appears loose, somewhat softened, wrinkled, and covered, more or
less, with patches of decidua. At the placental site the part is
raised, and the surface is unequal, like a granulating ulcer, and its
size is very much reduced. The whole internal surface of the
organ is of a dark ash color, with a greenish or brownish discharge
upon it, which has been mistaken for a gangrenous condition.
The uterine structure is not so dense as in its natural state ; its
fibers are more distinct, and the sinuses are still evident, being
filled with clots of blood at the placental site. The os and cervix
uteri appear bruised and ecchymosed, and small lacerations or
abrasions may sometimes be observed, which occasionally degen-
erate into ulcers. The orifice remains open for several days, clos-
ing gradually.

290

AMERICAN ECLECTIC OBSTETRICS.

The contractions of the uterus, which ensue after delivery, are
usually accompanied with more or less pain, termed AFTER-
PAINS, and which are more common to multiparous women than
primiparous ; being most generally absent in the latter. Females
who are the subjects of dysmenorrhea are said to be the most
liable to these pains, which vary greatly in their severity and dura-
tion. They commence soon after delivery, say from half an hour
to an hour, and continue from twenty-four to sixty hours. !No
bearing-down efforts accompany them, nor is the frequency of the
pulse increased. These pains are useful not only in reducing the
uterus to its non-gravid condition, but, by expelling coagula, pieces
of membrane, and the fibrinous clots which plug up the sinuses,
they prevent irritative fever. They are frequently brought on, or
increased, upon applying the child to the breast, which is an argu-
ment in favor of this being done at an early period after delivery,
in order to assist in promoting these contractions and thereby les-
sening the risk of hemorrhage.

After-pains may be usually distinguished from peritonitis, by
their periodical returns, by being unaccompanied with fever or an
excited pulse, by the persistence of the secretion of milk, and the
discharge of the lochia, and by not increasing in severity upon
pressure, though it must be recollected that the muscles of the
abdomen may feel sore when pressed upon. They require no
treatment unless severe, when they may be overcome by the
administration of Caulophyllin, compound powder of Ipecacuanha
and Opium, or these combined ; a mixture consisting of Camphor
one-third of a grain, Caulophyllin one grain, and Cimicifugin one
grain, has also been given with benefit — the dose may be repeated
every two or three hours. Should the pains resist the use of these
agents, and which resistance will usually be found to depend upon
retention of coagula, the rectum should be unloaded by a purgative
enema, and hot fomentations should be applied to the abdomen,
which will cause a prompt discharge of the clots, followed by
immediate relief to the patient. Equal parts of Hops and Tansy,
made into a fomentation with Whisky or some kind of Spirits,
and applied over the abdomen, warm, renewing it from time to
time, together with the internal administration of a mixture com-
posed of Caulophyllin two and a half grains, Compound Powder
of Ipecacuanha and Opium five grains, repeating this dose every
three hours, has, in my practice, afforded prompt relief in severe
after-pains that had obstinately resisted all previous treatment.

ATTENTIONS SUBSEQUENT TO DELIVERY.

291

Other remedies have been recommended in this difficulty, but
I have found the above all-sufficient in the numerous cases which
have come under my notice. There is a species of pain, of a very
excruciating character, which sometimes follows delivery ; it does
not intermit like the ordinary after-pains, but is continuous, and
is located in the coccyx and extremity of the sacrum. It may be
relieved by introducing an opiate suppository into the rectum,
or by the internal administration of the compound powder of
Ipecacuanha and Opium.

Rheumatism of the uterus may render the retraction of this
organ after delivery, very imperfect, causing it to continue enlarged
above the superior strait. In this case the after-pains are prolonged
and very severe, and the want of sufficient contraction upon the
bleeding vessels may give rise to profuse hemorrhage. This may
be overcome by pursuing a treatment similar to that named in
Chapter XXVIII, on "Difficult Labor" in the first stage, under
the head of Rheumatism of the Uterus.

In addition to the above-named conditions, there are several
others, which it is important to inquire into upon the first visit
after delivery; among these may be named the state of the excretions.
During the second stage of labor, perspiration becomes quite
copious, diminishing after the delivery, but not immediately
returning to the ordinary standard ; sometimes it has a greasy
feel, and a sickly odor, and the skin is soft and flabby, gradually
returning to its natural state.

Particular inquiry should be made as to the urinary discharge,
and on this point the practitioner should fully satisfy himself. It
is frequently the case, that the patient is unable to void the urine,
or it passes with difficulty, and in small quantity. This may dis-
tend the bladder, giving rise to pains, fever, violent spasms,, and,
perhaps, rupture of the bladder. Pressure of the head upon the
bladder and urethra, during its passage through the pelvis, usually
occasions this difficulty. "Whenever there exists any want of free
urination, the bladder should be at once emptied by means of a
catheter, which may have to be used several times before the parts
recover their tone sufficiently to do without it. In attending to the
evacuations, the patient should never be allowed to rise in the bed ;
it has often been the case that a sudden rising up in bed, within a
few days after delivery, especially when this has been accompanied
with hemorrhage, has been followed by immediate death. Dr. Meigs

292 AMERICAN ECLECTIC OBSTETRICS.

considers this to arise from the "heart clot" The excessive loss of
blood disposes the remaining portion of this fluid circulating in the
system to a ready coagulation ; consequently, if on rising, the
debilitated patient should faint, the activity of the circulation is-
impeded, and a mass of coagulated blood forms in the heart, filling
it so that the circulation can not be re-established, and death must
ensue ; or if this does not supervene, restoration takes place very
slowly, with symptoms of restlessness, difficult respiration, and a
peculiar action of the heart. Dr. Meigs says, that he has not seen
a patient, struggling and breathing violently, from the above cause,
who has ever recovered.

The condition of the bowels should likewise be inquired into ; if
the patient is doing well, and had a thorough alvine evacuation,
previous to delivery, there will be no necessity for any medication
in two or three days. But, if the bowels were costive, or if there
are febrile symptoms, restlessness, with slight pain upon pressure
of the abdomen, some mild laxative medicine should be adminis-
tered. Castor Oil is the agent most generally employed for this
purpose, but many females have an aversion to it, consequently
other laxatives will have to be used, as the compound powder of
Rhubarb, or an infusion of Senna and Cream of Tartar, etc. I
have frequently been called to patients, several days after their
delivery, who were suffering from pains in the abdomen, headache,
restlessness, and febrile symptoms, caused by the medical attend-
ant having neglected to evacuate the bowels, and in whom all
these symptoms disappeared, after the action of a dose of purga-
tive medicine. This inattention to the condition of the bowels of
the puerperal female, appears to constitute a part of the practice
of a certain class of physicians. It is, however, a very reprehensi-
ble omission.

The LOCHIA is a discharge which takes place from the partially
closed vessels of the uterus, and generally lasts five or six days, or
longer, until the womb is restored to its normal size ; though with
some females, the discharge continues until the re-appearance of
the menses. It is, at first, bloody, but in twelve or thirteen hours
becomes thinner and paler, changing to a discharge of bloody
serum. According to its color, the lochia is distinguished by the
names of sanguineous, sero-sanguineous, and purulent or puriform ;
it exhales a peculiar, disagreeable odor, varying in intensity with
different women, which is called gravis odor puerperii. During

ATTENTIONS SUBSEQUENT TO DELIVERY.

293

the milk-fever, the discharge generally ceases, but returns on its
subsidence, being then of a yellowish-white color; it varies in
quantity, being with some women very small, while others will soil
from six to fifteen napkins in the twenty-four hours ; but this
quantity gradually diminishes, and the discharge assumes a greenish
or paler color before it ceases. The lochial discharge serves to
relieve congestion, and to lessen the chances of an inflammatory
attack; during fever, it becomes checked, hence, its presence is
indicative of the absence of fever.

Generally, the lochia requires no interference ; it is only when its
condition affects the health of the patient, that medical attention
will be needed. Thus, it may be very small in quantity, but con-
tinue the usual time without any unpleasant results, and which is
apt to occur after flooding; or it may be abundant, and cease at
the usual time, without any detriment to health ; or, it may stop
shortly after delivery, without any evil consequences, as is fre-
quently witnessed in the case of still-born or putrid children.

Sometimes, however, the discharge is very excessive, producing
much debility; in these cases, remedies must be employed which
will diminish the quantity of the flow, as well as strengthen the
patient's system. To check the discharge, astringents may be em-
ployed ; a mixture of equal parts of Geraniin and Caulophyllin,
may be given, in doses suited to each particular case — commonly,
one or two grains of each, repeated every hour, will be sufficient.
Perchloride, or Persulphate of Iron will often prove serviceable, in
dilute solution. As tonics, Quinia, preparations of Iron, or some
qf the ordinary vegetable bitter agents, may be used ; the diet of
the patient should be more nourishing, but not stimulating, and she
should be kept in a state of rest and quietude. If with the exces-
sive discharge, there is vascular excitement, as quick pulse, heat of
surface, furred tongue, pain in the back, etc., the patient should be
placed on a low, mild diet, with cooling drinks, the bowels must
be gently moved by Seidlitz Powders, or other cooling laxative, and
the compound powder of Quinia may be administered with advan-
tage; sometimes the febrile symptoms may be overcome by the
saturated tincture of Aconitum root, given in doses of three drops in
a teaspoonful of water, and repeated every hour or two. I have com-
bined the saturated tinctures of Aconitum root and Cimicifuga, in
the proportions of one part of the former to two of the latter, and
have employed the mixture with advantage, in doses of eight drops
in a teaspoonful of water, every hour or two. Beside the sedative

294

AMERICAN ECLECTIC OBSTETRICS.

and antiphlogistic influence exerted on the system by these agents,
we also obtain the peculiar tonic action of the Cimicifuga upon the
uterus, thus rendering the compound a highly desirable one. The
generative parts should be bathed with cool water, three or four
times a day. Should the increase of the flow be owing to the
presence of a portion of the placenta within the uterine cavity, and
which may be presumed, if the discharge is offensive, with vomiting,
the vagina and uterus may be syringed two or three times daily
with some tepid, astringent infusion, as of Geranium, Hamamelis,
Quercus, etc.; and if the offending portion can be easily removed, it
should be done, when the symptoms are very urgent. Generally,
however, the uterus will evacuate its contents with more safety,
when not interfered with by injections or manual operations.

At times, the lochial flow, after having diminished in quantity,
suddenly becomes increased and of a red color ; this arises from the
patient sitting up too soon, or, at a later period, from too much
exercise, as of walking. Rest in the recumbent position will, usu-
ally, be the only treatment needed; but should it prove obstinate,
the red discharge still continuing, secondary hemorrhage may ensue,
for which the practitioner must be prepared — Ergot, Caulophyllin,
Oil of Fireweed, Geraniin, Warren's Styptic Balsam, etc., are among
the articles that may be used in these instances, together with a
confinement to the horizontal position.

The lochia may be checked, or deficient in quantity, from other
causes than uterine contraction, in which cases, febrile symptoms
will be present ; and if the discharge be not promptly restored, it
may form the basis of some fatal disease. The treatment which I
have found to be most commonly beneficial, is, to evacuate the
bowels by a mild purgative, after which, the patient is made to drink
freely of a strong infusion of the herb Leonurus Cardiaca, as hot as
can be borne, at the same time bathing the groins, thighs, and
inferior extremities with the officinal compound tincture of Cam-
phor. A plant called Winter Fern, is much employed, in infusion,
in many parts of the country for the same purpose as the Leonurus,
and, it is said, with considerable success, but I am unacquainted with
it. A large poultice of Elm bark, sprinkled wfth three or four
drachms of pulverized Camphor, and applied over the vulva and
abdomen, has also proved serviceable.

When the above treatment fails to remove the abnormal symp-
toms, they may be owing to inflammation of the uterus, or other
local inflammation, which will require to be treated upon general

ATTENTIONS SUBSEQUENT TO DELIVERY.

295

principles. I would remark here, however, that the combination of
the tinctures of Aconitum and Cimicifuga, above mentioned, with
attention to the condition of the bowels, and warm fomentations to
the abdomen, have been employed in my own practice very success-
fully. I have also administered the tincture of Gelseminum, in
these cases, with the most remarkable results. A similar course
may be pursued where the diminution of the lochial discharge is
owing to uterine rheumatism, which is apt to be the case when the
uterus is attacked by this disease. (See Chapter XXVIII.)

Sometimes the lochia has a very fetid odor, is acrid, and of a dark
color; this may be owing to putrefaction of retained coagula, or
decomposition of pieces of the placenta or membranes which have
been left within the uterus. An injection of warm water, of some
warm astringent infusion, or of a very weak solution of chloride of
lime, passed into the vagina two or three times daily, will be found
sufficient to remove the fetor. When the discharge continues of a
purulent character, long after delivery, with lumbar pains and sense
of weight accompanying, it may be owing to ulcers, or abrasions of
the cervix or vagina, which will have to be determined by the
speculum, and treated accordingly. When the lochia is acrid, an
infusion of Elm-bark and Black Cohosh root, may be injected into
the vagina, several times a day, with advantage.

With some women the secretion of milk is attended with con-
siderable vascular excitement ; rigors, headache, pains in the back
and limbs, quick pulse, furred tongue, etc., are present in a greater
or less degree. This condition is termed milk-fever, and is by no
means common to every parturient woman ; it usually manifests
itself in two or three days after delivery ; occasionally sooner, and
sometimes later. It may generally be avoided by placing the child
to the breast as soon after labor as is compatible with the strength
and condition of the mother, and by the early administration of a
purgative. It commonly lasts for twelve or twenty-four hours,
rarely forty-eight, and may be overcome by the use of cooling
purgatives, fomentations to the breasts, if they are full, hard, and
painful, and the frequent application of the child. When very
severe, diaphoretics may also be given. When the rigors are very
intense, or when the fever assumes periodicity, febrifuges and
antiperiodics must be administered, and the practitioner should be
on his guard lest it be attended with puerperal peritonitis.

Milk-fever is often occasioned, or aggravated by too long a delay

296

AMEKICAN ECLECTIC OBSTETRICS.

in giving suck to the child, and which may arise from deficient,
mal-formed, or sore nipples. Where the nipples are deficient or
mal-formed, the milk will have to be extracted by artificial means,
as the breast-pump. The secretion of milk is liable to become
diminished when the uterus is suffering under a rheumatic attack ;
and this, together with the severe pain, diminution of lochia, pain
on pressure, etc., may be readily taken for peritonitis. (See Chap-
ter XXVIII.)

Excoriation and ulceration of the nipples is a very common affec-
tion among nursing women, indeed, some suffer severely from it
after every confinement. It is, sometimes, so severe and painful
that it is impossible to bear the application of the child's mouth
to the nipple, and, in some instances, a persistence in suckling,
gives rise to large, foul, painful, superficial ulcers, or deep cracks,
which bleed upon every application of the child ; occasionally, the
woman loses her nipple. This difficulty may be obviated, by the
use of artificial shields, or prepared teats, which can be had in
every drug-store ; but frequently the child refuses to suck with
them, and the aid of the physician is demanded. Whenever
inflammation is present, it must first be subdued, previous to the
application of any healing salve or ointment. This may be
effected by a poultice of Elm bark, or Flax-seed, which should
cover the whole nipple and areola, after which any of the prepara-
tions named below may be applied. Sometimes, the inflammation
will be so intense, as to require the application of a few leeches on
the breast outside of the areola, before any benefit will result from
the emollient poultices. The severe pain may frequently be relieved ^
by a careful application of a solution of Nitrate of Silver to the
excoriated parts only ; the solution may be of the strength of from
two to six grains of salt to the fluidounce of water.

After the reduction of the inflammation, and in those cases
where it is but slight, the following applications have been recom-
mended : 1. Take of Spermaceti Ointment six drachms, Balsam of
Peru one drachm; mix together, and apply a small portion to the
nipples, several times a day. 2. Take of Mutton Suet one ounce, .
Balsam of Peru two drachms, Honey, Glycerine, of each one
drachm; melt the Suet, and add the remainder of the articles,
stirring well together. Use same as above. 3. Take of Balsam
of Tolu, Balsam of Peru, Honey, of each, fourteen drachms,
Camphor, Opium, of each, two drachms, Alcohol two pints ; mix
together and allow them to stand for seven days, frequently

ATTENTIONS SUBSEQUENT TO DELIVERY.

297

agitating them. A piece of linen is to be moistened with this, and
kept constantly applied to the nipple when the child is not suck-
ling ; if too severe, it may be slightly diluted with water. It must
be washed off every time previous to the application of the child.
I have used this successfully, in many cases. 4. Take of Beef-
marrow, Olive Oil, white Wax, of each two ounces, Cherry Wine,
made of common cherries {Cerasus avium, C. vulgarus, etc.,) two
fluidounces ; place the articles together in a vessel, apply it over a
gentle heat, and allow it to remain until all the wine has evapo-
rated. This ointment may be applied just previous to the child's
suckling, and immediately after. Should the child's mouth be
sore, this will have a tendency to heal it. It forms an elegant
preparation, one which I have successfully employed in the most
distressing and obstinate cases. And as my object is to render
this work one of practical utility, even in minor difficulties, I do
not hesitate to give publicity to these small details. 5. Take
of Glycerin, Tannin, each, two drachms; mix, dissolve the Tannin,
and apply frequently. 6. Take of Gum Tragacanth 8 to 15 parts,
Lime water 120 parts Glycerin 30 parts, Rose water 100 parts ;
mix, and employ in ointment or embrocation. I have fre-
quently been called upon to prescribe in cases of sore nipples,
which had baffled the treatment of four or five preceding medical
attendants, but which yielded at once to the course above-named.
Borax-water, Cucumber ointment, ointment of Poplar buds, and
Castor Oil, have likewise been advised as local applications: I have
not used them.

After having bestowed the proper attentions to the mother, and
ascertained the condition of the bowels, bladder, uterus, lochia,
pulse, breasts, etc., the practitioner may then inquire concerning
the child. Whether it has had evacuations from the bowels and
bladder, and whether it sucks. In cases where the urine is scanty,
or where there has been no urinary discharge, and the parts are
natural, requiring no surgical operation, the application of pounded
garlic, or onions over the pubic region will be very serviceable; if,
however, these do not cause a copious urinary discharge, and the
hypogastric region be swollen from accumulation of fluid in the
urinary bladder, it may become necessary to introduce a small
flexible catheter, in order to remove the urine, and which will be
found a difficult operation, requiring great care. If the bowels
20

298

AMERICAN ECLECTIC OBSTETRICS.

have not been evacuated, and there is no imperforate anus requir-
ing the surgeon's aid, a mild laxative as betore remarked, may be
given ; Castor Oil is usually preferred. The clothing of the child
should be warm, and loosely applied, that it may be free in its
motions; caps are to be avoided as injurious ; the dress should be
high up on the neck, with long sleeves ; and the diapers must be
soft, and never allowed to become dry and stiffen with the excre-
tions, and thus give rise to troublesome excoriations.

The only proper food for an infant, is its mother's milk, and
when this can be obtained, little else should be given it, for at least
six or seven months. All paps, panadas, gruels, and cordials are to
be avoided, and their use among infants, as food, can not be too
severely censured. Colics, diarrheas, green and watery stools, and
severe aphthous affections are the penalties of such unnatural prac-
tices. When the mother's milk can not be had, from whatever
cause, and a wet nurse is not at hand, and it becomes necessary to
feed the child, a mixture of one part of water to two or three parts
of cow's milk, and warmed, forms an excellent substitute for the
parent fluid. The milk used should be procured from one cow
regularly, and be given as soon as possible after it has been milked
out. The addition of sugar to the preparation, as advised by some
writers, I consider uncalled for and pernicious, frequently produc-
ing diseases of the stomach and bowels, which are attributed to
other causes. The following table, by Simon, showing the mean
of fourteen analyses, made at different periods, with the milk of
the same woman, and which very nearly corresponds with the
analyses of other investigators, will conclusively show the folly of
adding sugar to a preparation intended to supply the place of
breast- milk.

And as to the sugar of milk, it very nearly corresponds in
quantity to that of cow's milk, as may be seen by the following
analysis of this animal's milk, by Chevallier and Henri :

Water

Solid constituents

883.6
116.4
25.3
34.3
48.2
• 2.3

Butter
Casein

Sugar of milk, and extractive matters
Fixed salts

ATTENTIONS SUBSEQUENT TO DELIVERY.

299

Casein-
Butter*

4.48
•3.13
4.77
0.60
87.02

Sugar of milk
Saliue matter
Water

It will be observed that cow's milk contains more casein and
butter than human milk, which may, probably, lead to the produc-
tion of a still better substitute for this last, than the one proposed
above.

In feeding the child its artificial food, it should be done in a
manner to simulate, as closely as possible, the natural functions;
that is, it should not be fed with a spoon, but should be taught to
suck from a vessel, through some porous substance, by which
means the saliva is invited into the mouth to be swallowed with
the food, which latter is thereby rendered more easily digestible.

The parturient woman should be kept in a state of rest and quiet
for nine or ten days, in order that the uterus may return to its non-
gravid size without hemorrhage, inflammation, or displacement,
and that the system may fully recover from the shock given to it by
the labor. The first two or three days, she must not be allowed to
remove from the horizontal position, especially if the labor has
been protracted, or if there has been hemorrhage ; after this time,
if not contra-indicated, she may be permitted to sit up in bed a few
minutes at a time, or in a chair, while the bed is being fixed, and
should from this time lengthen the duration of sitting each day,
until there is no further occasiou for remaining in the bed. The room
should be well ventilated, but without exposing the patient, and
be kept clean, quite free from all unpleasant odors, and moderately
warm. The female should be kept clean, especially about the gen-
itals, which must be frequently bathed with lukewarm water, or
warm water and spirits; and her diet must be light and of easy
digestion, especially during the first days. Gruel, mush and milk,
toast, panada, arrowroot, rice, etc., are all that can be permitted
until the fifth or sixth day, when, if she be doing well, the use of
soft-boiled eggs, oysters, and weak soups, may be allowed. After
the tenth day, and during the puerperal month, animal food, fowls,
and other diet of a nourishing but non-stimulating character, may
be given ; if she be weak, a little porter will be admissible.

If the patient, previous to pregnancy, was afflicted with prolap-

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AMERICAN ECLECTIC OBSTETRICS.

sus uteri, a continued recumbent position for eight or ten weeks
after delivery, will contribute much toward a radical cure.

The visits of the practitioner should be daily, for the first two
or three days, or oftener, if required ; after which, a visit every
second or third day, made on two different occasions, will be suffi-
cient in ordinary cases. However, this is governed by custom ;
in some places, after the first visit succeeding delivery, no other
is made, unless the physician is sent for; in others, the visits are
continued more or less often, as may be required, until the ninth
or tenth day. I consider the last-named plan of visiting, the pre-
ferable one, both as regards the safety of the woman, and the
reputation of the accoucheur.

CHAPTER XXVI.

PRESENTATIONS AND POSITIONS.

For the purpose of more clearly understanding the mechanism
of labor, it is necessary that a knowledge of the various presenta-
tions and positions of the fetus, be had. By the term presentation,
in obstetrics, is meant the part of the fetus which occupies the pel-
vic superior strait at the commencement of labor ; while position
designates the relations which the presenting part assumes with
the circumference of this strait, or with some fixed point. Thus,
if it is said the vertex presents, we understand it to mean a presenta-
tion of the head, in which the head of the child will be the part
first delivered; if it is still further said, that it is in the left occipito-
anterior position, we learn that the occiput of the child looks
toward the left acetabulum of its mother, while its forehead is
toward her right sacro-iliac symphysis, and the sagittal suture will
consequently be found running in an oblique direction in the pel-
vis between these two points — or, in other words, we have the
position in which the head presents.

There are two PRESENTATIONS recognized in obstetrics-
one Cephalic, the other Pelvic. The cephalic, is divided into ver-
tex, face, and shoulder presentations ; the pelvic, into breech,
knees, and feet. Occasionally, some portion of the trunk may
present, or perhaps the ear and side of the head, but these are so

PRESENTATIONS AND POSITIONS. 301

extremely rare, as to form exceptions rather than exemplifications ;
and their management would be similar to that recommended for
arm or shoulder presentations.

The most common, as well as the most favorable presentation
for both mother and child, is that of the vertex or head, and which
alone constitutes a natural labor; the others are only deviations.
That this is the fact may be gathered from the following statistics :
Bland records 1792 head presentations in 1897 cases of labor ;
Dubois 10,262 in 10,742; Kluge 257 in 298; Lovati 61 in 67;
Mazzini 439 in 452; Nfegeie 1,210 in 1,296; Pacord 49 in 53;
Ramoux 266 in 275; Riecke 214,134 in 219,258; Siebold 132 in
137 ; Smellie 920 in 1,000 ; and Velpeau 392 in 400.

The relative frequency of the various presentations, are given
in the following table, taken from Churchill's Obstetrics :

Author.

Total No.
of cases.

Head presen-
tations.

Breach pre-
sentations.

Inferior ex-
tremities.

Superior ex-
tremities.

20,517

19.810

372

238

80

15,652

14,677

349

255

68

10,387

9,748

61

184

48

2,947

2,735

78

40

19

640

619

2

3

1

2,452

2,225

17

8

4

839

786

21

4

691

645

14

7

4

16,414

15,912

242

187

40

1,182

1,105

28

15

4

4,666

4,266

59

29

12

1,640

1,119

35

22

9

The POSITIONS of the two presentations and their divisions
or deviations, vary considerably, so much so that some authors
have given one hundred and two distinct positions. (Baudelocque.y
But these have recently been so reduced and simplified by Nsegeie,
Dubois, Stoltz, and other accoucheurs that the whole of them may
be comprised in sixteen positions, and which will be found fully
sufficient for all practical purposes. The many slight alterations
and deviations in position, which may occur with the several pre-
sentations, and which have given rise to the numerous positions
above referred to, may, singly, either be reduced to some one of the
distinct positions, hereinafter named, before the termination of
labor, or may hold such a close relation to it, as to require no
material difference in its management.

In a VERTEX PRESENTATION, although it may become
necessary to determine the situation of the anterior and posterior

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AMERICAN ECLECTIC OBSTETRICS.

fontanelles, and the direction assumed by the sagittal suture, in
order to ascertain its position, yet it is the posterior fontanelle
alone, which distinguishes the situation of the occiput ; and, this
fontanelle, in all natural labors, is the most readily reached by the
finger. A vertex position is characterized by the relation existing
between the occiput of the fetus, and the acetabulum, symphysis
pubis, or sacro-iliac symphyses of the maternal pelvis. Thus then,
the positions of a vertex presentation, may be arranged as follows :

POSITIONS OF VERTEX PRESENTATION.

1st. LEFT OCCIPITOANTERIOR, in which the occiput of
the child looks toward the left acetabulum of the mother, or ante-
riorly and to the left of the pelvis. In this position the forehead
of the child, and consequently the anterior fontanelle, will be
found toward the right sacro-iliac symphysis, the sagittal suture
running obliquely across the pelvis anteriorly from the left, to the
right posteriorly. This position has also been called the left oeeipito-
cotyloid.

2d. RIGHT OCCIPITOANTERIOR, in which the occiput of
the child looks toward the right acetabulum of the mother, or
anteriorly and to the right of the pelvis. In this position, the
anterior fontanelle will be found toward the left sacro-iliac sym-
physis, the sagittal suture running obliquely across the pelvis
anteriorly from the right, to the left posteriorly. This position
has also been called the right occipito-eotyloid.

3d. OCCIPITO-PUBAL, in which the occiput faces the sym-
physis pubis of the mother, or is placed anteriorly without any
lateral obliquity. In this position, the anterior fontanelle will be
toward the sacrum, the sagittal suture running in the direction
of the antero-posterior diameter of the pelvis.

4th. LEFT OCCIPITO-POSTERIOR, in which the occiput
looks toward the left sacro-iliac symphysis of the mother, or poste-
riorly and to the left of the pelvis. In this position, the fore-
head of the child, or its anterior fontanelle, will be found toward
the right acetabulum, the sagittal suture running obliquely across
the pelvis anteriorly from the right, to the left posteriorly as in
the second position. This position has also been called the right
fronto- cotyloid.

5th. RIGHT OCCIPITO-POSTERIOR, in which the occiput
looks toward the right sacro-iliac symphysis of the mother, or
posteriorly and to the right of the pelvis. In this position, the

PRESENTATIONS AND POSITIONS. 303

forehead of the child, or its anterior fontanelle, will be toward the
left acetabulum, the sagittal suture running obliquely across the
pelvis anteriorly from the left, to the right posteriorly, as in the
first position. It has also been called the left fronto -cotyloid.

6th. OCCIPITO-SACRAL, in which the occiput faces the
sacrum of the mother, or is placed posteriorly without any lateral
obliquity. In this position the anterior fontanelle will be found
toward the symphysis pubis, the sagittal suture being in the same
direction as in the third position.

The student can readily master a knowledge of these positions,
if, taking the vertex or occiput as the guide, he will bear in mind,
that it may be placed either anteriorly or posteriorly in the maternal
pelvis, and that, commencing with its anterior position as the first,
he has merely to give to it the directions, left, right, and front.
Thus, vertex to the left anterior, vertex to the right anterior, vertex
anterior, vertex to the left posterior, vertex to the right posterior,
and vertex posterior. Professor Meigs simplifies the positions, the
better to impress them upon the student's mind, thus : " vertex left,
vertex right, vertex front ; forehead left, forehead right, forehead
front," and which enumeration is, undoubtedly, as he remarks, "the
easiest one to remember." The importance of a knowledge of these
positions, is, that in cases where an interference is demanded, the
accoucheur may have a certain guide by which to govern his opera-
tions, with an eye to the safety of the mother, as well as of the child ;
and, without this knowledge, any assistance which may be
attempted, is more likely to effect mischief than benefit. And I hold
a man, who is ignorant of these matters, criminally responsible for
any fatal consequences that may follow his rash attempts to accom-
plish— he knows not what. Nor is the excuse, " that he has no
malice or evil feeling toward his patient, but was endeavoring to
do the best he could for her," a valid one — he has no right, what-
ever, even with the authority of a diploma, to undertake a practice
which concerns health and life, with an entire ignorance of his
duties; the very attempt alone, is, in my estimation, criminal.

"When the head presents well flexed, it is a vertex presentation,
but when extension has occurred, it then becomes a FACE PRE-
SENTATION, in which but two positions are recognized. In the
diagnosis of face positions, the mentum or chin of the child, must
be taken as the guide.

Although the labor in face presentations is tedious, and more

304

AMERICAN ECLECTIC OBSTETRICS.

painful to the mother, and somewhat more dangerous for the child
than in vertex presentations, yet we find that in the majority of
cases they terminate naturally, and without any artificial aid.
From statistics collected from French, German, and English
authorities, it appears that in 136,123 cases, the face presented in
640, or about 1 in 212J cases, so that these deviations of the
natural vertex presentation are very rare. As to the labor, we
have a record of 344 cases, in which 248 were delivered naturally,
42 required version, 20 the forceps, and 15 craniotomy. The mor-
tality to the mother averages about 1 in 50; to the child 1 in 7;
and it has been found the greatest to both mother and child in
those cases where assistance was given; so that the necessity for
interference is not so great as was formerly supposed.

POSITIONS OF FACE PRESENTATIONS.

1st. LEFT MENTO-ILIAC, in which the child's chin is to the
left side of the maternal pelvis, and its forehead to the right side.

2d. EIGHT MENTO-ILIAC, in which the chin of the child is
to the right side of the mother's pelvis, and its forehead to her
left side.

Some authors give two other positions, one the mento -sacral, in
which the chin is toward the sacrum, and the forehead toward the
pubic symphysis, and the other, the mento -pubic, exactly the reverse
of the preceding one. The former is said to be extremely rare,
and I very much doubt whether it can occur, except in children
with very small heads, or in premature labors. The latter is like-
wise seldom met with, although it is the position which the two
principal positions assume at the termination of labor.

A SHOULDER PRESENTATION" may be considered a devia-
tion of the cephalic presentation, and includes those of the arm,
elbow, and hand; according to statistics it has occurred 358 times
in 93,398 cases, or about 1 in 260f , and its mortality to the mother
is about 1 in 9, while of the children rather more than one-half
have been lost. There are four shoulder positions ; two for each
shoulder, and the points by which the practitioner is to be guided
in his diagnosis, are, the head of the fetus, and the ilium of the
mother; some authors name the back of the fetus instead of its
head. The right arm or shoulder presents oftener than the left.

PRESENTATIONS AND POSITIONS.

305

POSITIONS OF SHOULDER PRESENTATIONS.

FIRST LEFT CEPHALO-ILIAC, in which the right shoulder
presents, the head of the fetus being in the maternal left iliac
fossa, its face looking posteriorly, and its back anteriorly. This is
likewise called the first anterior dorsal position.

SECOND LEFT CEPHALO-ILIAC, in which the left shoulder
presents, the head of the fetus being in the maternal left iliac fossa,
its face looking anteriorly, and its back posteriorly. This is like-
wise called the first -posterior dorsal position.

FIRST RIGHT CEPHALO-ILIAC, in which the right shoulder
presents, the head of the fetus being in the maternal right iliac
fossa, its face looking anteriorly, and its back posteriorly. This is
likewise called the second 'posterior dorsal position.

SECOND RIGHT CEPHALO-ILIAC, in which the left shoulder
presents, the head of the fetus being in the maternal right iliac
fossa, its face looking posteriorly, and its back anteriorly. This is
likewise called the second anterior dorsal position.

The PELVIC, or BREECH PRESENTATION, is divided into
four positions, the sacrum of the fetus being the diagnostic guide.
In this presentation, the delivery is generally accomplished by the
natural powers, without the intervention of art, though it is slow,
tedious, and painful to the mother, and more dangerous to the
fetus than vertex, or face presentations ; the mortality to the child
is owing to pressure of the os uteri on its body, which, by forcing
the blood toward its head, produces congestion of that organ ; it
may also be owing to the tardiness of the labor, and the compres-
sion of the cord during the delivery of the head. Why the breech
should present, has not been satisfactorily explained. Breech
presentations have occurred, according to statistics, 2,438 times in
129,117 cases, or about 1 in 52, and the mortality to the child is
recorded at 195 deaths in 678 cases, or about 1 in Z\ Knee and
feet presentations are mere deviations from the breech, and are
even more tedious and dangerous to the child than this, on account
of the delay in the delivery of the head, the maternal parts not
being so well dilated, as when the breech presents, with the
extremities flexed upward. Knee presentations are rare, occurring
about once in 3,445 cases ; statistics give 1,268 foot and knee
presentations in 117,640 cases, or about 1 in 92f, and the mortality
to the child is recorded at 210 deaths in 562 cases, or about 1 in 2J.

306

AMERICAN ECLECTIC OBSTETRICS.

POSITIONS OF BREECH PRESENTATION.

1st. LEFT SACRO-COTYLOID, in which the sacrum of the
fetus faces the left acetabulum of the mother's pelvis, while the
posterior part of the fetal thighs, which are flexed upward, faces
the right sacro-iliac symphysis. This position is also called the
left sacro-iliac.

2d. RIGHT SACRO-COTYLOID, in which the sacrum of the
fetus faces the right acetabulum of the maternal pelvis, while the
posterior part of its flexed thighs faces the left sacro-iliac sym-
physis. This position is also called the right sacro-iliac.

3d. SACRO-PUBIC, in which the sacrum of the fetus faces the
maternal symphysis pubis, while the posterior part of its flexed
thighs faces the sacro-iliac symphyses.

4th. SACRO-SACRAL, in which the sacrum of the fetus faces
the maternal sacrum, while the posterior part of the flexed thighs
faces the pubes of the mother.

Two other positions are given by some authors, in which the
sacrum of the child is to one or the other of the sacro-iliac sym-
physes; I doubt very much whether these occur, except in very
small children, and when they do, the management will be the same
as in the positions given.

In KNEE PRESENTATIONS, the feet are always to be brought
down, and the positions of the feet are determined by the heel ; that
is, 1st, heels to the left, or left calcaneo-iliac ; 2d, heels to the right,
or right calcaneo-iliac ; 3d, heels to the front, or pubes, or calcaneo-
pubal; and 4th, heels to the back, or sacrum, or calcaneo-sacral. The
position of the heels enables us more readily to determine the posi-
tion of the breech. '

To briefly recapitulate, the presentations and positions are as
follows :

Presentation}.

Positions.

Presentations.

Vertex.

1. Left Occipito anterior.

2. Right Occipitoanterior.

3. Occipito-pubal.

4. Left Occipito-posterior.

5. Right Occipito-posterior.

Shoulder.

1. First Left Cephalo-iliac.

2. Second Left Cephalo-iliac.

3. First Right Cephalo-iliac.

4. Second Right Cephalo-iliac.

1. Left Sacro-cotyloid.

2. Right Sacro-cotyloid.

3. Sacro-pubic.

4. Sacro-sacral.

Face.

6. Occipito-sacral.
f 1. Right Mento-iliac.
I 2. Left Mento-iliac.

Bbeech.

MECHANISM OF LABOR.

307

CHAPTER XXVII.

MECHANISM OF LABOR.

It has been heretofore remarked, that presentation of the vertex
is the most common of all ; and among the positions, the left occipito-
anterior, or that in which the occiput is directed toward the left
acetabulum, is most frequently met with, occurring, according to
statistics, about 69 times in every 100 cases. In 1,913 cases, reported
by M. Dubois, 1,339 were left occipitoanterior, 494 right oceipito-
posterior, 55 right occipito-anterior, and 12 left occipito-posterior.
Why the occiput is found so much more frequently in front is diffi-
cult to determine ; but its position at the left anterior of the pelvis,
may be accounted for by the rectum on the left side, which, being
usually distended with fecal matters, diminishes the right oblique
diameter, so that the head being forced to traverse tbe most ample
diameter, the occiput is thrown to the left acetabulum, and the fore-
head to the right sacro-iliac symphysis.

As already remarked, vertex presentations are always more favor-
able for both mother and child, than any other. The occipito-pos-
terior positions are, however, less so than the occipito-anterior, in
consequence of the difficult descent of the head, the more frequent
demands for,. artificial aid, the greater liability of laceration, or per-
foration of the perineum, and from the delay in the advance of the
head often creating sloughs, and urinary, or stercoral fistulse.
? The presence of a vertex presentation may frequently be recog-
nized during the last few weeks of pregnancy, even before the finger
can be introduced within the os-uteri ; a regular, solid, rounded
tumor may be felt through the inferior portion of the uterine
parietes, which can be raised by the finger with more or less diffi-
culty as the pregnancy is more or less advanced. And when, at the
commencement of labor, the presenting part can not be easily
reached, or the round, resisting surface of the head is not encount-
ered, there may be some other than a vertex presentation, and the
labor should be closely watched during the first stage, in order to
determiue, as soon as possible, the nature of the presenting part,
and be thereby enabled to rectify, at the proper period, any acci-
dents which may present themselves. Nsegeie states, that various
circumstances, independent of malposition, may occur, which will
prevent the presenting part from being felt at the end of gestation ;
as in cases of multipara, where the uterine fundus is strongly

308

AMERICAN ECLECTIC OBSTETRICS.

inclined forward; in twin cases; in breech presentations; where a
large quantity of amniotic fluid is present; where the uterus is not
oval at its inferior part ; when there is a hydrocephalous head'; and
where the pelvis is narrow. As soon as the dilatation of the os
uteri has so far proceeded as to admit the introduction of the finger,
during the absence of a pain, the large, rounded, smooth and solid
surface of the head can be felt through the membranes, and if the
dilatation be sufficient, membranous spaces, answering to the sutures
and fontanelles, may be recognized ; and if the head be pressed
upon, a resistance of a somewhat elastic character may be noticed.
After the membranes have ruptured, these diagnostic signs are
more manifest.

After having correctly ascertained the presentation, the next thing
will be to determine the position, and this should always be done at
as early a period as possible, in order, the more readily to remedy
any difficulties which may occur. The diagnosis can, in many
instances, be effected previous to the rupture of the membranes ;
but, most frequently, it will be impossible to arrive at it, until after
this has occurred, and then, it should always be accomplished with-
out delay.

Auscultation has been spoken of, as affording aid in determining
the position ; thus, if the fetal heart is heard pulsating in the left
iliac fossa, the occiput is to the left, and if in the right, it is to the
right, etc. ; but there is too much uncertainty in this mode of
diagnosticating, to admit of its employment in actual practice ; the
examination per vaginam is the only one on which dependence
must be placed. The same may be said in relation to the active
motions of the fetus, whose anterior region is supposed to corre-
spond with the point of the uterus at wtich these have been
recognized for a long time. The practitioner may attend to these
symptoms, for the purpose of verifying their accuracy, or of lead-
ing to a more positive determination of their real value; but he
should not allow a labor to proceed solely upon the indications
they afford.

In order to arrive at the position of a vertex presentation, the
accoucheur should render himself enabled to recognize at once, the
character of the fontanelles and sutures, a description of which is
given in Chapter VI, and the exploring finger should be pressed
with sufficient firmness upon the head, to enable it to detect them.
He must also bear in mind that, frequently, while the head is
descending, the compression it undergoes, is such, that the bones

MECHANISM OF LABOR.

309

are forced to overlap each other, and the sutures, instead of a
membranous sensation, convey to the finger, one of longitudi-
nal ridges or prominences; and the distinctive character of the
posterior fontanelle especially, is lost, being recognized merely by
the junction of the sagittal and lambdoidal sutures, or rather the
longitudinal prominences which they present from the pressure.

1st. LEFT OCCIPITO-ANTEPJOR POSITION.

DIAGNOSIS. — In this position, the finger, upon being intro-
duced into the vagina, will first come in contact with the boss or
protuberance of the right parietal bone of the fetal head, and not
the posterior fontanelle, which latter will be found in the region
of, and corresponding nearly to the maternal left acetabulum ; the
sagittal suture may then be traced running from this triangular
fontanelle, obliquely across the pelvis, from below upward, and
from before backward, and from left to right, until it meets with
the large, soft, Fig. 46.

membranous, and
quadrangular ante-
rior fontanelle,
which will be to-
ward the right
sacro-iliac symphy-
sis. The back of
the child will be
toward the front
and left of the
mother's abdomen,
while its abdomen
will be toward her
back and right ; its
right shoulder will
be in front and to
the right, and its
left, back and to
the left. {Fig. 46.)

MECHANISM.
The waters having
been discharged by
the rupture of the membranes, the expulsive contractions of the
uterus force the head, which presents obliquely at the superior

310

AMERICAN ECLECTIC OBSTETRICS.

strait, down into the brim of the pelvis, its flexion upon the chest
is increased, so that the neck is bent more into a curve, and the body
of the fetus is more or less compressed and rolled, as it were, into a
ball, occupying much less space than before. At first, the two fonta-
nelles are nearly on a level, but as labor progresses, and the head
advances, one of them, more commonly the posterior, will be found
gradually descending, as the uterine contractions cause the vertex
to sink. The flexion causes a change in the relations of the head.
Previous to the rupture of the membranes, and the flexion of the
head, the occipito-frontal diameter of the fetal head was parallel
to the left oblique diameter of the superior strait, and the biparie-
tal of the former coincided with the right oblique of the latter;
but now, while the position of the latter diameters remains unal-
tered, the former changes, the occipito-bregmatic of the fetal head
corresponding to the left oblique diameter of the strait, in place of
the occipito-frontal. The axis of the pelvis, which, previous to
the rupture, coincided with the trachelo-bregmatic diameter of the
head, now corresponds very nearly with its oceipito-mental. If
the student will compare the diameters of the fetal head with
those of the maternal pelvis, he will ascertain that this movement
of flexion, brings the smallest diameters of the head in correspond-
ence with the smallest of the pelvis, thus placing it in a position
highly favorable to its ready expulsion.

The descent of the head is due to the continuation of the uterine
contractions, which force it through the strait, into the pelvic
cavity, and onward to the lower strait of the pelvis. In its passage
through the pelvic excavation, it undergoes great compression, the
bones overlap each other, as above stated, forming longitudinal
ridges along the sutures, and sometimes, when the pressure is very
considerable, a tumor is formed upon the scalp, called the caput
succedaneum. The obliquity of the head at the superior strait is
preserved throughout its descent, with the exception that one fon-
tanelle is, most commonly, lower than the other. The contrac-
tions urge the head downward, the occiput descends on the left
antero-lateral inclined plane, while the forehead moves in the direc-
tion of the right sacro-iliac symphysis, and the descent is wholly
perfected, when the occipito-bregmatic circumference coincides with
the plane of the inferior strait, or when the two protuberances of
the parietal bones have arrived at this level, and to attain which,
the left protuberance, which is behind, must traverse the whole

MECHANISM OF LABOR.

311

Fig. 47.

anterior face of the
sacrum, describing
the arc of a large
circle, while the
right, which is an-
terior, traverses a
shorter distance, de-
scribing the arc of
a much smaller cir-
cle.

When the head
arrives at the floor
of the pelvis, its fur-
ther progress is ar-
rested by the peri-
neum, sacro-sciatic
ligaments, etc., etc.,
which form this
part; but the con-
tinuation of the
uterine contractions
effects a movement
of rotation from left
to right, in which the occiput is passed behind the symphysis
pubis, a little to its left, while the forehead rotates into the hollow
of the sacrum, remaining, however, a little to the right. (Fig. 47.)
In this situation the occipito-mental diameter of the head is almost
parallel with the axis of the inferior strait, and the sagittal suture
nearly coincides with the antero-posterior diameter of this strait.
As the resistance at the floor of the pelvis is gradually overcome,
the occiput continues to descend, passing under the arch of the
pubis until the neck comes in contact with it, when its further
advance is arrested. At the period when the occiput is engaged at
the pubic arch, the shoulders and upper part of the body engage
in the superior strait with their long diameters in the same direc-
tion as was taken by the biparietal diameter of the head, viz .: its
right oblique diameter.

The neck being immovably fixed against the pubis, the contrac-
tile efforts being always in a line with the axis of the superior
strait, are directed upon the chin, or that portion of the head
which lies in the concavity of the sacrum ; the chin gradually

312

AMERICAN ECLECTIC OBSTETRICS.

Fig. 48. departs from the chest, while the ocsi-

put ascends, forming the motion of ex-
tension. (FigAS.) During this extension,
with the neck fixed against the symphy-
sis pubis as a pivot for the head to turn
upon, the forehead and face pass over
the curves of the sacrum, coccyx, and per-
ineum, and as the head emerges, the
vulva becomes distended, the labia majora
are effaced, the nympha? are pressed up,
the perineum becomes thin, yielding, and
distended, and the sagittal suture, ante-
rior fontanelle, forehead, nose, mouth,
and chin, appear in succession at the
vulva, and the head is born. It must be remarked here, that
although the fetal head is impelled toward the outlet during each
pain, yet its remission is followed by a recession of the head; and
this may frequently be observed when the occiput, which has
appeared at the vulva during a pain, recedes within the cavity
during its cessation, having the labia closed over it. This reces-
sion is of immense benefit to the woman, as the distension of the
parts is thereby relieved. Were the head to be forced onward
without any such relief, the circulation in the parts would be
obstructed, the vessels would be more or less strangulated, and
inflammation, followed by gangrene, would be very apt to ensue-
From a similar cauce, it is likewise advantageous to the fetus, an
undue and constant pressure upon the head of which, would be
likely to cause its death.

The passage of the fetal head through the pelvic cavity is often
accompanied with cramps in the inferior extremities, which do not;
however, interfere with the action of the uterus or the progress
of the labor, but are sometimes so agonizingly painful as to demand
„a hastening of the delivery with the forceps : the cramps are
owing to the compression of the internal sacral nerves by the head.

A few seconds after the delivery of the head, it undergoes another
motion, called restitution, in which it becomes directed as it was
previous to rotation, that is, with the face looking toward the
internal posterior surface of the right thigh of the mother, and the
occiput toward her left groin. {Fig. 49.) From a supposition that
the rotation was effected without any participation of the body
therein, merely occasioning a twisting of the neck, and that after

\

MECHANISM OF LABOR.

313

the birth of the head, Fir,. 40.

the neck untwisted,
restoring the head to
its natural relations
with the body, the
term restitution was
applied to this last
motion. J3ut, accord-
ing to Gerdy, this
view is erroneous, for
the trunk does rotate
with the head in such
a manner as to bring
the^long diameter of
the shoulders, which
was at first in the
direction of the right
oblique diameter, to
nearly correspond with the transverse diameter of the pelvic cavity.
They descend and reach the floor of the pelvis in this transverse
position, which presents their bis-acromial diameter to the small,
or bis-ischiatic diameter of the inferior strait, rendering it almost,
if not quite impossible for them to be delivered. Consequently,
the resistance offered to their further advancement, at this point,
by the uterine contractions, as was the case with the head, estab-
lishes a rotation, wdiieh causes the right shoulder to pass from
the right side toward the pubic arch, while the left passes into the
concavity of the sacrum, and the bis-acromial becomes nearly
coincident with the antero-posterior diameter of the inferior strait^
and it, is this rotation of the shoulders which causes the motion
of the head called restitution ; it necessarily following the impulse
impressed on the shoulders.

Sometimes, however, the head executes a motion, a short time
previous to its restitution, and which occurs immediately after its
expulsion. This appears to be owing to a slightly oblique position
of the shoulders, while the occiput is about passing under the
pubes in an antero-posterior direction, which imparts a slight twist
to the child's neck, and from which it is relieved, as soon as the
head is delivered, and free from the soft parts.

Shortly after the expulsion of the head, the shoulders having
executed the motions above named, the right shoulder appears at
21

314

AMERICAN ECLECTIC OBSTETRICS.

the vulva and is fixed against the pubes, while the posterior or left
shoulder traverses the perineal cavity in the same manner as the
face in the delivery of the head, and after its disengagement at the
anterior commissure of the perineum, the right or sub-pubic
shoulder follows. During the birth of the shoulders, the trunk of
the child becomes curved laterally, so as to correspond with the
curvature of the pelvic excavation; the concavity being on its
right side, and the convexity on its left.

Frequently, the right shoulder will be the first delivered, or both
shoulders may emerge from the vulva at the same time. After the
delivery of the shoulders, the remainder of the body is easily
expelled, describing in its passage, a more or less marked spiral
movement.

Thus, then, in a natural labor, with an occipitoanterior posi-
tion, we have the head to offer its smallest diameters and circum-
ference to those of the pelvis, and to perform the motions of flexion,
descent, rotation, extension, and restitution.

2d. RIGHT OCCIPITO-ANTERIOR POSITION.

DIAGNOSIS. — In this position, the finger will first come in con-
tact with the left parietal protuberance, and the posterior fontanelle
will be found corresponding to the right acetabulum ; from this
fontanelle may be traced the sagittal suture, running obliquely
across the pelvis from below upward, and from before backward,
and from right to left, until it meets the anterior fontanelle, which
will be toward the left sacro-iliac symphysis. The back of the
child will be toward the front and right of the mother's abdomen,
while its abdomen will be toward her back and left : its left shoul-
der will be in front and to the left, and its right, back and to the
right. {Fig. 50.)

Madame Boivin records 3,682 instances of this position in 20,517
cases, or about 1 in 5| cases. Nsegeie states that though more
cases/are terminated in this position, yet that its frequency as an
original one is .07 per cent. Between this and the previous posi-
tion there will be found but little difference in practice. Dewees
states that on account of the right lateral obliquity of the uterus
prevailing so often, and the rectum being occasionally impacted
with hardened feces, this position is less favorable than the first ;
but, he adds, we may control the obliquity by placing the woman
upon her left side, and can empty the rectum by an injection.

MECHANISM OF LABOR.

315

MECHANISM. F.a 50.

In the right occip-
ito-anterior posi-
tion, the occipito-
frontal diameter of
the tetal head is
parallel to the right
oblique diameter of
the superior strait,
and the hi parietal
of the former coin-
cides with the left
oblique- of the
latter : but, as in
the first position,
when the mem-
branes rupture and
the head descends,
the occipito-breg-
matic diameter of
the head takes the
place of the occi-
pitofrontal, the
biparietal remaining unaltered. The flexion, descent, rotation,
extension, and restitution are the same as in the previous position,
with the exception that rotation takes place from right to left, and
restitution directs the face toward the internal posterior surface of
the left maternal thigh, and the occiput toward the right groin.
The delivery of the shoulders is likewise the counterpart of the
first position.

31. OCC'IPITO-PUP.AL POSITION.

DIAGNOSIS. — In this position the occiput, or posterior fonta-
nels, will be detected behind the symphysis pubis, and the sagittal
suture may be traced, running parallel to the antero-posterior
diameter of the pelvis, from before backward and upward, until it
meets the anterior fontanelle, which will be towTard the sacrum.
The back of the child will* face the mother's abdomen, while its
abdomen will be toward her back; its right shoulder will be
toward her right side, and its left toward her left.

This position occurs but very rarely, though Nsegele considers it

.316

AMERICAN ECLECTIC OBSTETRICS.

to be the original one in all occipitoanterior positions, these being
merely secondary transformations of it, and recognized only
because the examination is made at too advanced a period.
Baudelocqne met with it twice in 10,329 cases; Madame Boivin 6
times in 20,517 ; and Madame La Chapelle, not once in 30,000.

MECHANISM. — In the occipito-pubal position, the occipito-
bregmatic diameter of the fetal head, corresponds with the antero-
posterior pelvic diameter, and its biparietal with the pelvic
transverse. The mechanism differs from the two preceding
positions, in the head executing only the motions of flexion,
descent, and extension; as rotation is unnecessary, and the direc-
tion of restitution will depend entirely upon which shoulder
engages at the pubic arch, as rotation of the shoulders must eusue,
before they can be delivered. The labor, if not interfered with by
any uterine obliquity which will remove the head from the center
of the pelvis, will be as favorable as in either of the preceding
cases.

Labor may be facilitated, when the head is in this position,
makiug but little advance, by changing it to one of the occipito-
anterior positions, especially when the vertex is high up, and
manifests no disposition to assume one of these positions after the
occurrence of three or four pains. To effect this change, the head
may be grasped between the thumb and fingers, and the face
inclined laterally ; but the operation must not be attempted until
the os uteri is well dilated, the soft parts yielding, and the head at
the superior strait, not impacted, but free and movable, and during
the absence of pain. If the change can not be effected, we must
then wait until symptoms present themselves indicating the neces-
sity of interference by forceps or otherwise.

4th. LEFT OCCIPITO-POSTERIOR POSITION.

DIAGNOSIS. — In this position the occiput is placed at the left
sacro-iliac symphysis, and the forehead at the right acetabulum.
The anterior fontanelle will be found behind the right acetabulum,
from which the sagittal suture may be traced running obliquely
across the pelvis, from before backward, and from above down-
ward, and from right to left, until it meets with the posterior
fontanelle, which will be toward the left sacro iliac symphysis.
The back of the child will be toward the back of the mother
and to the left, while its abdomen will be toward her abdomen,

MECHANISM OF LABOR. 317

t

and to the right; Fig. 51.

its right shoulder
will be toward her
abdomen a n d to
the left, and its left
to her back and
right. {Fig. 51.)

This position is
very rare, occur-
ring, according to
ifcegele, in the ratio
of .03 per cent. ; to
La Chapelle of .04
per cent.; and to
Boivin of .05 per
cent. It is more
unfavorable than
the right occipito-
posterior position,
the labor being-
more painful and
protf acted ; this
arises from causes
similar to those named under the second position, and may bo
remedied to a certain extent, bv the same means as therein
mentioned.

MECHANISM. — If the examination per vagi nam be made »\
an early period, before the head has undergone much flexion, the
occipito frontal diameter will be found to coincide with the rigid
oblique pelvic diameter, and the biparietal with the left oblique.
With the descent of the head, the same as in the previous posi-
tions, flexion takes place, which changes the situation of the head
so as to bring the occipito-bregmatic diameter in correspondence
with the right oblique diameter of the pelvis; and the occipito-
mental diameter of the head runs nearly parallel with the axis of
the superior strait. At first the anterior fontanelle will be found
in the center of the pelvis, but as the head becomes flexed and
descends, it rises, while the posterior fontanelle, previously beyond
the touch, descends, and engages in the pelvic cavity. The descent
occurs in the same manner as already described in the preceding
instances. When the head has reached the floor of the pelvis,

318

AMERICAN ECLECTIC OBSTETRICS.

rotation, which is much more extended than in the occipitoante-
rior positions, takes place, the occiput describes an arc from left to
right, and is carried round to the symphysis pubis, when the head
is delivered in the same manner as if it had been an original ante-
rior position. This extensive rotation could not be effected with
safety to the child, unless the body participated in the motion, and
which must of course require a long time to accomplish ; but
when completed, the labor proceeds favorably, the right shoulder
is soon brought under the pubic arch, and the left passed into the
sacral concavity, and the delivery is terminated as usual. The
movement of restitution places the face of the child toward the
internal part of the right maternal thigh, and its occiput toward
the internal part of the left thigh. It is often the case in this
position, and especially in primiparous women, that nature becom-
ing exhausted, artificial assistance is demanded.

Fig. 52. The above method is

the one in which deliv-
ery is most commonly
effected in the posterior
occipital positions, but
occasionally it occurs in
another way. When
the head arrives at the
floor of the pelvis, the
rotation places the fore-
head under the sym-
physis pubis, and the
occiput in the hollow of
the sacrum. {Fig. 52.)
In this position the face
of the child will be to
the front of its mother,
and its back to her
sacrum ; the occipito-
frontal diameter of its head will coincide with the pelvic antero-
posterior, and the biparietal will be transverse, as well as the
bis-acromial.

In this position, the uterine contractions still further increase the
Bexiou of the head, the occiput is forced to gradually traverse the
sacral, coccygeal, and perineal curve, the perineum becomes greatly
distended and elongated, the occiput passes over the posterior com-

MECHANISM OF LABOR.

319

missure, and the head passes out by its occipitofrontal diameter.
As the occiput is passing outward, the forehead rises behind the
symphysis pubis, thus giving more space for the head to pass
through. Sometimes, after the delivery of the occiput, the neck
becomes fixed against the perineum, and the forehead, face, and
chin of the child, successively emerge from under the pubic arch.
Should the forehead descend so low that the eyebrows may be felt,
it will, by presenting an impediment to its elevation behind the
pubic symphysis at the time of the passage of the occiput over the
perineal curve, very much increase the difficulty of the labor.

Dr. Dewees states, " We almost always have it in our power to
reduce this and the fifth " (when they occur with the occiput in the
hollow of the sacrum, as just described), " one to the second, and
the other to the first, and we should always do so when nature does
not do it for us. Nor is this change of position of the head an
operation of the slightest difficulty to the accoucheur ; neither does
it cause the smallest pain to the patient, provided, advantage be
taken of the proper conditions of the uterus, and head of the
child, and state of the labor. For the uterus must be well dilated,
the membranes ruptured, the head occupying the lower strait, and
the labor active. When these pre-requisites obtain, the point of the
fore-finger must be placed against the edge of the sagittal suture
either before or behind the anterior fontanelle ; and in the absence
of pain, this part must be pressed toward the left sacro-iliac sym-
physis,* and maintained there during the subsequent contraction of
the uterus. Should this attempt fail in changing the position of
the head, by bringing the posterior fontanelle to the right acetabu-
lum, the attempt must be repeated again and again until it succeed;
which it will, almost constantly do."

The expulsion of the head in the occipital posterior positions,
may, in consequence of a premature extension, fix the occiput in
the hollow of the sacrum, and thus the face be forced downward by
the contractions, delivery occurring as in face presentations ; but,
in order to effect such a change in the pelvic cavity, the natural
size of the head must be considerably reduced, or the diameters of
the excavation must be very large.

* In the fourth position of the vertex, while attempting the above reduction, the for&
head must be pushed toward the right sacro-iliac symphysis, which will reduce it to the
first position; in the fifth position, the pressure must be made in the direction toward
the left sacro-iliac symphysis, which will place the head in the second position. — Author.

320

AMERICAN ECLECTIC OBSTETRICS.

In all the occipito-posterior positions, there may be a failure of
complete rotation, a want of energy of uterine contraction, or
exhaustion, etc., either of which will require the interference of art.

5th. RIGHT OCCIPITO-POSTERIOR POSITION.

DIAGNOSIS. — In this position the occiput is placed at the right
saero-iliac symphysis, and the forehead at the left acetabulum, the an-
terior fontanelle will be found behind the left acetabulum, from which
the sagittal suture may be traced running obliquely across the pelvis,
from in front backward, and from above downward, and from left to
right, until it meets with the posterior fontanelle. which will be toward
the rig-lit sacro-iliae symphysis. The back of the child will be toward
Fig. 53. the back of the mo-

ther and to the right,
while its abdomen
will be toward her
abdomen, and to the
left ; its right shoul-
der will be toward
her back and to the
left, and its left to
her abdomen and
right, {Fig. 53.)

This is considered
the most common
of the occipito-pos-
terior positions, and
is stated by Nasgele,
to be the next in
frequency, a mong
the vertex presenta-
tions, to the left oc-
cipitoanterior, oc-
curring in the ratio
of 29 per cent. In
355 cases, related by Simpson, 256 were in the first position, 1 in the
second, 2 in the fourth, and 76 in the fifth. Its frequency is sup-
posed to be owing to the same cause which gives rise to the left
occipitoanterior position, viz.: the pressure of the rectum on the
left side of the pelvis, which happens especially, when, as is com-
mon to women advanced in pregnancy, there is an accumulation of

MECHANISM OP LABOR.

321

hardened feces. It is a more* unfavorable position than the first
three, and the labor, though generally accomplished by the natural
powers, is more tedious and painful, than with the occipito-anterior
positions.

MECHANISM. — This is the counterpart of the fourth position,
and difficulties or changes maybe encountered, similar to those
met with in that position. At the commencement of labor, the
occipitofrontal diameter will be found to coincide with the left
oblique pelvic diameter, and the biparietal with the right oblique
the two fontanelles, as in the preceding case, being at nearly the
same level. As the labor advances, flexion ensues, and the
occipito-bregmatic diameter takes the place of the occipitofrontal,
the axis of the superior strait corresponding nearly with the
occipito-mental diameter. Flexion, descent, rotation and restitu-
tion, occur as in the preceding case, with the exception, that the
rotation takes place from right to left, the left shoulder is brought
to the pubic arch, and restitution brings the face of the child
toward the internal part of the left maternal thigh, and its occiput
toward the internal part of the right thigh.

6th. OCCIPITO-SACRAL POSITION.

DIAGNOSIS. — In this position the forehead or anterior fonta-
nelle will be detected behind the symphysis pubis, and the sagittal
suture may be traced, running parallel to the antero-posterior
diameter of the pelvis, from before, backward, and downward,
until it meets the posterior fontanelle or occiput, which will be
toward the sacrum. The back of the child will face the mother's
back, while its abdomen will be toward her abdomen ; its right
shoulder will be toward her left side, and its left toward her right.

This position is of very rare occurrence, so much so that its exist-
ence is doubted by some accoucheurs, and, together with the third,
it is not classified as a position by several authors. In 20,517
deliveries it was met with but twice. — Boivin. f

MECHANISM.— In the occipito- sacral position, the occipito-
bregmatic diameter of the fetal head corresponds with the antero-
posterior pelvic diameter, and its biparietal with the pelvic trans-
verse. The mechanism differs from the two preceding positions,
in the head executing only the motions of flexion, descent, increased
flexion and extension. The motion of rotation is unnecessary, and
the direction of restitution will depend upon which shoulder
engages at the pubic arch. If nature does not reduce this to an

322

AMERICAN ECLECTIC OBSTETRICS.

occipito-posterior position, and the labor is slow and painful, it
may be facilitated by effecting the reduction artificially, in the same
manner, and guided by the same rules, as named, when treating of
the mechanism of occipito-pubal positions. The head may present
in positions not exactly agreeing with those just given, relative to
which, Dr. Dewees very correctly remarks : " Mathematical pre-
cision is not required in such cases, especially as the mechanism of
the labor is not altered ; for, when the posterior fontanelle is at all
in advance of the sacro-iliac junction, either right or left, it will
almost always eventually place itself under the arch of the pubes,
and this is all that is necessary."

It may be proper to remark here that sometimes the movements
of the head do not occur exactly in the manner just described.
Flexion, for instance, will be found to occur previous to the descent
of the head, or simultaneously with it, or not until the head has
reached the pelvic floor; and, occasionally, extension will take
place so far as to gradually place the anterior fontanelle in the
center of the pelvic cavity, flexion occurring, however, as soon
as the descent is completed; this last irregularity is more usual
with occipito-posterior positions. Again, Dubois has met with a
few cases, in which excessive flexion brought the posterior fonta-
nelle to the center of the excavation (or perhaps, an inclination of
the trunk backward, may have effected it), but which was restored
to its proper situation upon meeting with the resistance from the
pelvic floor.

Rotation may also vary ; it may commence while the head is at
the upper part of the pelvic cavity, so that flexion, descent, and
rotation occur simultaneously; or it may not take place until the
head has almost passed the posterior commissure of the vulva.
Rotation may also be incomplete, or it may be so extensive as to
carry the occiput, not only to the pubic symphysis, but even beyond
it, to the acetabulum of the opposite side; in these latter instances,
after a short period of rest, it again places itself behind the
symphysis, by a retrograde motion. These irregularities are not
easily accounted for, and though they may render the delivery
tedious, yet it will generally be effected without any artificial
interference.

Rotation of the shoulders likewise, offers some irregu arities ; it
may be wanting, or it ma}' be incomplete, or it may be excessive,
the same as with the rotation of the head.

MECHANISM OF LABOR.

323

The pressure upon the circumference of the head, produces a
sero-sanguineous engorgement over the part not subjected to the
compression, and which is always the lowest or presenting part.
This tumor, caput succedaneum, may become so developed as to
obscure the diagnosis, or lead to the supposition of a breech pre-
sentation ; but, if the finger be carried beyond its circumference,
the bony resistance of the head will determine the presentation.
The diagnosis of the position, may, however, not be so readily
ascertained, as this engorged condition of the scalp may prevent
the detection of the fontanelles ; in such cases, the delivery will
require to be performed without interference, bearing in mind, that
in Vertex presentations, the major part are delivered by the unaided
efforts of nature.

This tumor of the scalp is an unerriug indicator of the position
of the fetal head ; thus, in the left occipitoanterior position, it will
be found on the right parietal protuberance, and in the right
occipitoanterior on the left; in the occipito-posterior positions,
it is located about the center of the vertex, sometimes on the ante-
rior foutanelle, but, generally, to correspond with the part origi-
nally at the os uteri, and subsequently with the part which presents
under the pubic arch.

It may be distinguished from a sanguineous tumor of the head,
which Naegeie has termed cephalcematoma, by the following charac-
teristics: it is irregularly circumscribed, being larger in proportion
to the tediousness of t^he labor; is always single; is (edematous,
retaining the pit of the finger ; has no fluctuation ; and the scalp
is of a well-marked violet color. The cephalsematorrja vary in size,
from a small nut to a hen's egg; it is distinctly circumscribed;
possesses a well-marked fluctuation, sometimes pulsations; its cen-
ter is sometimes so greatly depressed, as to be mistaken for
a perforation of the bone ; its base is limited by a prominent
osseous border, which, however, is often not developed for several
days after the commencement of the disease; and the skin cover-
ing it is colorless. Again, the caput succedaneum appears directly
after birth, and disappears in from twelve to forty-eight hours,
while the eephalsematoma seldom appears until some hours after
the delivery, and lasts for several weeks. — Cazeaux.

324

AMERICAN ECLECTIC OBSTETRICS.

CHAPTER XXVIII.

ON DIFFICULT LABOR. FIRST STAGE.

Difficult, lingering, tedious, and protracted labor, belongs to
the second class, and includes all labors where the fetal head pre-
sents, but where they continue beyond twenty- four hours, and
may require some medicinal, manual, or instrumental aid. It is
true, that cases will be met with, in which artificial delivery may
be required within the twenty-four hours, and others, again, which
may continue for a period considerably beyond twenty-four hours,
but these instances form exceptions to the above definition. As
a general rule, however, the one given will be found exceedingly
salutary and beneficial in practice, and an attention to which, will
be calculated to prevent the occurrence of any mischief from a rash
or premature interference of the practitioner.

The danger in a difficult labor, depends entirely upon the stage
in which the delay happens; thus, the first stage of labor may
continue for even sixty or seventy hours, with but little, if any
danger, especially if the membranes remain entire, and there is
'a proper amount of liquor amnii present, and no mechanical
impediment exists. But delay in the second stage, is always
attended with danger, if it continues beyond a comparatively short
time; hence, in estimating the necessity for interference, we are
not to be governed so much by the length of time occupied by the
first stage, as by the interval which has elapsed since the rupture
of the membranes and the discharge of the amniotic fluid ; and
the experience of accoucheurs has demonstrated that the danger
is, commonly, in proportion to the duration of the labor. From
statistics of the Dublin Lying-in-Hospital, it appears that when
labor exceeds thirty hours, one woman in thirty-four dies ; when
it exceeds forty hours, one in thirteen dies; beyond fifty hours,
one in eleven ; and beyond sixty hours, one in eight.

Difficult labors are more common among primiparre, and are,
likewise, not unfrequent among multipara? who have given birth
to a large number of children. According to the statistics of Eng-
lish obstetricians, 653 cases of difficult labor occurred in 23,758,
or about 1 in 36 ; and it will frequently happen, that a practitioner
in his individual private practice, may meet with even a much
larger average than this.

The continuance of a labor beyond a period of twenty-four hours

DIFFICULT LABOR — FIRST STAGE. 325

is necessarily calculated to arouse the fears of the patient and her
friends, as to the cause of the delay; and if the practitioner does
not proceed properly in such iustances, the anxieties and doubts
of the friends may lead them to require the aid of a second
accoucheur, or perhaps the dismission of the first. It is therefore
always proper, when the labor has continued thus long, to institute
a careful investigation of the condition of the patient, and of all
the presenting symptoms, for the purpose of learning the cause
of the delay, and at once applying the remedy. " In estimating
lingering labors, we calculate from the first commencement of true
uterine action ; but in estimating the length of labor, in reference
to the patient's strength and its effects on her system, we princi-
pally take into consideration the time that has elapsed since the
membranes broke; for it is reasonable to infer that no great exer-
tion has been sustained, consequently that little or no exhaustion
has appeared : and particularly, that scarce any injurious pressure
can have taken place on the soft parts within the pelvis, while the
membranous cyst remained entire, provided there be an ordinary
quantity of liquor amnii. Thus, when called to a case of lingering
labor, in considering the chance of injury from its duration, our
mind should be directed, not so much to the interval which has
elapsed since the first accession of uterine pains, as to the time at
which the membranes ruptured; and that should be looked upon
as the period when it was possible for dangerous pressure to have
commenced." — Ramsbotham.

The management of a patient in difficult labor must be similar
to that required in natural labor. She should not be kept in one
position, but should be allowed to sit, walk, or lie down, as she
may prefer, and more especially in the early part of labor; in the
latter stage, circumstances may require her to preserve the recum-
bent posture. She must not bear down or make any efforts to
assist the uterus during its contractions, as such efforts may cause
the membranes to give way prematurely, exhaust the patient's
strength uselessly, or otherwise interfere with the progress of the
delivery ; and this is a point which can not be too strongly insisted
upon. It is only during the second stage of labor, when the pre-
sentation and position are both favorable, that the action of the
muscles of the abdomen may be exerted with advantage. The
room should be kept cool and quiet, to prevent fever and induce
sleep. Bland, nourishing fluids, weak tea, or acidulated draughts,
may be allowed, but stimulants and solid food must be prohibited.

326 AMERICAN ECLECTIC OBSTETRICS.

Too frequent vaginal examinations are injurious, but the condition
of the bladder should be ascertained every two or three hours, and
much urine should not be allowed to collect in it. This is of
especial importance in difficult labors : the urine must be passed
often, either naturally or by catheter ; and in the use of the latter,
no force should be employed, and care must be taken not to per-
mit it to slip into the bladder. If the metallic instrument can not
be introduced, an elastic catheter must be substituted ; and although
under ordinary circumstances no exposure of the female is allowable,
yet there may be instances where, from the failure in introducing tin
above instrument, and the condition of the parts, an exposure will
be necessary to accomplish the desired evacuation of the bladder.
This, however, must never be practiced, except under the most
imperative requirements. This class of labor may be owing to one
or more of several causes, which I shall now proceed to designate
and treat upon.

A very common cause of protracted labor is, INEFFICIENT
ACTION OF THE UTERUS, in which the contractions are par-
tial, feeble, or irregular : they may continue only for a few seconds,
they may hardly be appreciable, or they may occur at irregular
and lengthy intervals; and in each instance, the os uteri may be
soft and dilatable. This cause will, in some cases, be owing to a
torpid, inactive, and sluggish condition of both mind and body, or
a want of proper nervous irritabiity in the constitution; to some
depressing action, as debility resulting from excessive discharges,
previous disease, etc.; to sudden and violent emotions of the mind,
and other circumstances which exert an influence on the brain and
nervous system. Debility of the system, or even the presence of
serious disease, does not invariably occasion inertia of the uterus,
for we frequently meet with females laboring under tubercular
phthisis, hectic fever, etc., who pass through their labors with great
facility. With some females the tendency to difficult or easy
deliveries appears to be a peculiarity transmitted from parent to
child, and occurs independent of any abnormal conformation, or
habit of the system. A deranged condition of the digestive
organs will frequently influence the character of the uterine con-
tractions, as will likewise irritation of the os or cervix uteri.

Females are often annoyed, at the close of gestation, with false,
spasmodic, or irritable pains, which have no connection whatever
with the contractions in the fibers of the uterus, and which have,
in some instances, given rise to the absurd statements that labor has

DIFFICULT LABOR — FIRST STAGE.

327

continued uninterruptedly for one, two, or more weeks. Care
should be taken to distinguish these from the proper contractions
of the uterus.

Inefficient action of the uterus may occur during the first or
second stage ; and, as before remarked, the danger is greater in
the latter than in the former instance. In the First Stage we may
find the pains feeble or irregular, and exerting but little influence
upon the bag of membranes ; yet if there is only a slight increase
of the pulse, " with the surface of the body cool, tongue moist,
absence of thirst, no tenderness of the abdomen on pressure, no
heat or tenderness of the vagina and os uteri, and dilatation is
advancing, however slowly, we ought not to interfere, for many
hours may elapse before this stage will be completed, and yet the
pressure of the fetal head upon the soft parts will produce no evil
effects if the apartment be kept cool, the posture be occasionally
changed, voluntary efforts at bearing down be avoided, and noth-
ing but mild nourishment and diluents be allowed."

TREATMENT.— When there is considerable delay in the
advancement of the first stage of labor, the patient should be kept
in as cheerful condition as possible, and she may occupy the time
by walking about — but not to cause fatigue — by reading or sew-
ing, by frequently changing her position, etc.; and should be
encouraged to exercise patience, which virtue the practitioner will
find equally demanded on his part. If the bowels have not been
freely evacuated, a stimulating enema or a dose of purgative medi-
cine may be given, and which will frequently arouse the uterus to
increased action. If the pulse is weak and slow, and no heat, but
rather coolness of the surface, nor hemorrhage, some arrowroot,
or gruel, or wine and water, may be beneficial, but their use should
be permitted with caution. If, from the want of sleep, continued suf-
fering, and anxiety of mind, the patient should become fatigued or
exhausted, a soporific dose of opium or some of its preparations
should be administered, or any other hypnotic ; upon awakening
from the influence of which, she will not only feel refreshed, but
will very likely have a recurrence of the pains with increased
energy. And the opiate should always be preceded by a purgative
when constipation exists.

If there is a plethoric condition of the uterus, or an irritated state
of the os and cervix uteri, this may be frequently overcome by the
use of diuretics and diaphoretics ; and as a diuretic, in these
instances, I prefer an infusion of the Cleavers {Galium aparine), or

328

AMERICAN ECLECTIC OBSTETRICS.

of the Hair-cap Moss (Polytrichum juniperum), with the compound
powder of Ipecacuanha and Opium as the diaphoretic. Plethora
of the uterine tissue may be known by the energy with which the
pains are at first manifested, but which soon diminish in frequency
and intensity. The cervix is soft and yielding, but the presenting
part does not engage during the pain ; the pulse is hard and full,
the respiration laborious, and the pains are equally diffused over
the whole abdomen.

Sometimes the employment of warm diluent drinks, as of tansy,
pennyroyal, etc., with frictions over the abdomen, will frequently
succeed in restoring or increasing the contractions, without other
aid being required.

"When the pains occur at very irregular periods, are confined to
the uterus, and do not render the bag of waters tense, nor impart
any hardness to the uterus when felt through the abdominal
parietes, the pulse being quick and full, and the uterus unusually
developed, the inertia is owing to an Excess of Liquor Amnii, over-
distending the organ, or perhaps to the presence of Twins. In this
case, although the soft parts are relaxed and dilated or dilatable,
the labor does not progress any, the uterus being, from this cause,
rendered incapable of contracting sufficiently powerful to rupture
the membranes, and the patient becomes fretful and restless. The
only remedy in this case, is a discharge of the liquor amnii by an
artificial rupture of the membranes, which should be done during
the absence of pain, and made as high up as possible, in order to
avoid a falling or washing down of the cord ; though I would
especially desire to impress it upon the mind of the student, that
this procedure is entirely unjustifiable in ordinary labors, and must
not be attempted unless it is well ascertained that there is no
mechanical impediment, that the head presents, and the os uteri is
dilatable. A premature rupture of the membranes, by discharging
the bag of waters and bringing the hard and unyielding head of the
child upon the sensitive os uteri, may delay the labor by lessening
the pains, or producing rigidity of the os. Still-born children are
more frequently the results of too early rupture of the membranes,
and, probably, the use of instruments are likewise oftener required
in such cases.

If the relaxation or cessation of uterine contractions depends
upon moral influences, the attendant, by ascertaining the trouble,
may perhaps, by a prudent and sagacious course, remove them; but
if this is impossible, he will be governed by the effects produced,

DIFFICULT LABOR — FIRST STAGE.

329

using stimulant? vi case of depression, and sedatives where much
nervous excitement exists ; and in these latter instances the induc-
tion of sleep will frequently be followed by uterine efforts.

I am decidedly opposed to the use of ergot during the first stage
of labor, where the only difficulty is the inefficiency of the uterine
contractions, for, as a general rule, an attention to the various
symptoms which may present themselves, during this stage, with
their appropriate treatment, will be all that is demanded. But,
should circumstances require the use of agents which exert a par-
turient influence upon the uterus, the infusions of the recent bark
of the Cotton root, or Black Cohosh root, or Blue Cohosh root will
prove, as a general rule, more salutar}7 than the ergot ; these infu-
sions should be used warm, and in doses of from two to four fluid-
ounces every half hour or hour. Of the latter articles, their con-
centrated preparations, Cimicifugin, or Caulophyllin, in doses of
from one to three grains, given as above; will be found equally
beneficial. Occasionally, females will be met with, upon whose
uterine system these agents produce but little, if any influence, and
in whom, under imperious circumstances, it may become necessary
to administer ergot, but I shall have occasion to refer to these cases
hereafter, as well as to others in which ergot may be employed.
Usually, however, the remedies above noticed, both during the first
and second stages of labor, will prove fully as efficacious as ergot,
without any of its injurious tendencies.

RHEUMATISM OF THE UTERUS may be present during
the non-gravid condition of the organ, at an early period of gesta-
tion, and at the time of labor during either of its stages. It is pro-
duced by the same causes that favor the development of rheumatism
in other parts, as exposures to cold and moisture, insufficient cloth-
ing, sudden changes of temperature, especially from a high to a low
one, and occasionally, from a rheumatic metastasis ; females constitu-
tionally disposed to rheumatism are more liable to it, though it fre-
quently exists without any other part of the system being affected by it.

" The most prominent symptom of this disease is pain, or a dis-
tressing sensation, without any appreciable cause, and which may
involve the whole or only a portion of the uterus. The intensity of
the pain is variable, and the whole organ may suffer from it, or only
a part, as the fundus, corpus, or cervix. The location of the pain
depends upon the portion of the organ which is affected ; thus if it
be seated in the fundus, the sub-umbilical region will suffer the
22

330

AMERICAN ECLECTIC OBSTETRICS.

most ; if in the inferior portion of the uterus, acute dragging sen-
sations will be experienced extending from the loins to the groins,
thighs, and external genital organs. Pressure upon the organ aug-
ments the pain, and if the inferior part of the womb be affected,
much suffering will be caused by pressure upon the cervix during a
vaginal examination. Frequently the contractions of the abdominal
muscles, or even the weight of the bedclothes, will increase the pain.
The pains, as with all rheumatic affections, frequently metastasize,
and pass from one point of the organ to another, or to some other
organ, and not unfrequently disappear suddenly. Remissions occur
sometimes, during which, a sensation of weight in the part is
experienced. Recto-vesical tenesmus almost always accompanies
the pain, and the evacuation of urine is attended with considerable
smarting and acute pain, and at other times the evacuation of both
the bladder and rectum is impossible. The pain is usually attended
with febrile symptoms, but sometimes these are absent. A repeti-
tion of the attacks of pain is very apt to occasion uterine contrac-
tions, which may determine an abortion.

" When rheumatism of the uterus occurs during labor, it gener-
ally impedes the progress of the labor, and sometimes, even prevents
the spontaneous expulsion of the child. Normal contractions of the
uterus only begin to be painful, when it has accomplished the greater
part of its task, and is in the act of distending and dilating the os
uteri ; or in other words, true labor-pains begin only at the instant
when the energy of the corpus uteri overcomes the resistance of the
cervix. "While in rheumatism of the uterus, the contraction is pain-
ful from the first, and before any influence is exerted on the cervix ;
so that the cause of the pain is not in the violent distension of the
os uteri, but in the contraction itself, in the other morbid conditions
and in the altered relations of the nerves and contractile fibers of the
uterus.

"Again, in a natural labor, the contractions commence at the
fundus, and are directed toward, and terminate at the cervix. In
rheumatism, instead of commencing at the fundus, they begin at the
painful part, and run toward the cervix in an irregular manner. The
rheumatic pains also exist before the uterine contractions, and under
the influence of the latter, they rapidly acquire a high degree of
intensity ; and sometimes their violence arrests the contractions
before they have traversed their ordinary cycle, in which case they
are rapid, short, and grow less and less frequent.

" Toward the close of the labor, when the action of the uterus

DIFFICULT LABOR — FIRST STAGE.

331

requires to be aided by the voluntary contraction of the abdominal
muscles, the female, for fear of augmenting her sufferings refrains
from contracting these muscles, thereby causing the labor to be
excessively slow. She is in a state of extreme anxiety, with an
increase of the frequent pulse, the hot skin, the thirst, and urinary
tenesmus. "When these sufferings are much prolonged, she falls
into a state of swooning, which frequently proves serviceable, as the
pains are suspended while it lasts; under these circumstances a
profuse perspiration has been observed, which has had a most salu-
tary influence on the rest of the labor. But, in other instances, the
uterus becomes more and more painful ; it is rather in a state of
permanent contraction or fibrillar vibration, than of normal contrac-
tion ; the pulse^being accelerated, and the woman threatened with a
metritis, which renders the labor extremely painful." — Cazeaux.

Uterine rheumatism is frequently mistaken for acute inflamma-
tion of the womb, and as the symptoms resemble each other very
much, it is very difficult to discriminate between them. Rheuma-
tism attacks mostly very nervous and susceptible women, and may
be more readily suspected when the patient has had previous attacks
of rheumatism or neuralgia, in other parts. Cazeaux determined
the disease by touching; thus, rheumatism and inflammation of the
uterus are both painful; but in rheumatism, although the first
touch of the womb is painful and quick, yet upon gently and
slowly raising it upward with the index and middle finger, the pain
either ceases altogether, or is much mitigated, by removing the
tenesmus uteri ; while in inflammation the touch becomes more
painful the more it is prolonged.

TREATMENT.— The means which may be adopted with benefit
in these cases, are various. In the first place the bowels, if they
have not been previously evacuated, must be emptied by an injec-
tion ; if the pain be not very severe, but troublesome and annoying,
the compound powder of Ipecacuanha and Opium, may be given in
doses of five or ten grains, and repeated every half hour or hour ;
or the compound tincture of Virginia Snakeroot, may be used as a
substitute for this powder, in doses of one or two fluidrachms. If
there are marked remissions, the compound powder of Quinia may
be given in doses of three or six grains, and also repeated every
half hour or hour. Fomentations of Stramonium leaves, or other
narcotics, may also be advantageously applied over the abdomen,
and when the pain is very severe, much benefit will be derived from
the application of dry cups over the lateral inferior portions of the

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sacrum. Should the disease manifest itself soon after the sudden
disappearance of a rheumatic pain in some other part, revulsives or
counter-irritants should be placed over the part primarily affected,
for the purpose of recalling the pain, if possible, to that part.

Other means may likewise be used, with equal, if not greater
advantages, in some cases, than those just named ; for instance,
the tincture of Gelseminum may be exhibited in one or two flui-
drachm doses, and repeated according to circumstances; or it
may be combined with one-third or one-half its quantity of tinc-
ture of Black Cohosh, or tincture of Lobelia, or tincture of
Aconite root. The compound tincture of Lobelia and Capsicum,
will most generally give prompt relief, if exhibited in large doses,
as from two to four fluidrachms, with rectal injections of the same
tincture slightly diluted.

The disposition to uterine rheumatism at the period of labor,
may in most instances, be entirely overcome by the use of the
compound syrup of Partridgeberry during gestation. General
venes'ection, although it may afford relief, is never necessary, as its
results are ultimately more disastrous to the patient than bene-
ficial, and a more permanent advautage is gained over the disease
by the above course, than could possibly be effected by the employ-
ment of the lancet ; and by pursuing it, there will exist but little
necessity for forceps, unless other symptoms, not immediately con-
nected with the rheumatic attack, are present.

RIGIDITY OF THE OS UTERI, during the first stage of
labor, is a frequent cause of its protractedness. This may occur
in any case, but is more frequently met with in primiparse, in
females of an advanced age, and in instances where the mem-
branes are prematurely ruptured. It may be occasioned by
repeated and unnece3sary examinations, the use of stimulants,
mental excitement, constipation, or retained urine. It may also
be owing to dysmenorrhea, or a diseased condition of the os itself,
either natural, or effected by the improper use of pessaries or
other mechanical aids to support the uterus, as well as the impru-
dent application of escharotics to the os, for the removal of some
real or imaginary affection.

Rigidity of the os uteri may be suspected in cases where the
head presents and the pains are regular and normal, but dilatation
proceeds very slowly, if at all ; in addition to which, Madame La
Chapelle refers to another symptom, viz. : pains in the loins. On

DIFFICULT LABOR — FIRST STAGE.

333

examination, the os uteri will be found thin, resisting, hot, dry,
and painful to the touch, or, soft, cedematous, serai-pulpy, and
undilatable, and which must be carefully distinguished from the
soft and flabby condition into which the thin and rigid cervix
must pass before it will dilate. Sometimes the rigidity is exces-
sive, the os being unusually dense, feeling like cartilage, with a
stubbornly unyielding edge ; or if this be thin, the same resistance
will be met with, and a sensation is conveyed to the touch, similar
to that produced by a hole made in thin, extended parchment.

Very frequently the rigidity will not be confined to the os uteri,
but will extend into the vagina and soft parts ; they will be found
hot, dry, swollen, and extremely sensitive to the touch, and if this
condition be not overcome, the patient becomes restless and
feverish, the pulse rises to 100 or 110, and finally, exhaustion of
the vital forces manifests itself. Occasionally the os uteri will be
found to contract during a pain, remaining rigid in the interval ;
and in such instances a rupture of the uterus may occur.
Instances are recorded in which the rigidity was so obstinate
that the os uteri has been torn off and expelled in the form of a
ring.

TREATMENT. — Among many writers, venesection, ad deli-
quium, animi, is considered the most successful and potent remedy
in this difficulty, and is the one on which the utmost reliance is
placed by the major part of the profession. I admit that bleeding
will overcome rigidity of the os uteri, as a general rule, but then I
by no means admit it to be a proper or safe remedy. A female in
labor requires all the strength natural to her system, not only to
sustain her during its progress, but also to enable her to withstand
and quickly recover from the nervous shock. By the loss of an
amount of blood sufficient to cause syncope, a debility of the
nervous and circulatory systems must ensue, producing a condition
unfavorable to either of these requirements ; and I have frequently
witnessed a tedious second stage, with subsequent hemorrhage or
other evils, following a bleeding practiced in the first stage, and
which I had every reason to believe were augmented, if not
actually produced by the venesection. Debility of the system, and
more especially when sudden, persistent, and at the period of par-
turition, is incompatible with a safe or energetic labor. Beside the
weakening influence of venesection upon the constitution, we
have an increased prostration of nervous and muscular force, pro-
duced by the shock imparted to the brain and nervous system, as

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AMERICAN ECLECTIC OBSTETRICS.

well as by the loss of blood which necessarily follows the birth of
every child. Indeed, it is impossible for any practitioner to deter-
mine what amount of blood may be lost from the labor itself,
independent of any artificial discharge; and who can tell how
many precious lives have been lost from uterine hemorrhage, or
other fatal symptoms, in the practice of believers in this treat-
ment, which might have been preserved had the lancet been cast
aside? Indeed, so well are the adherents of this practice satisfied
of its danger to the parturient woman, that they especially caution
us not to resort to it, until the parts become swollen and tender, the
pulse increased, with febrile symptoms, or a tendency to cerebral
congestion ; and even then we are advised to use it with care.
The injurious tendencies of bleeding do not cease with the com-
pletion of delivery, for whether it be artificially effected by the
lancet, or naturally by uterine hemorrhage, not only is the puer-
peral month one of slow, tedious convalescence, if this term can
justly be applied to it, but very frequently, a lifetime of irreme-
diable suffering and disease is the inevitable consequence.

In the treatment of this difficulty, we have no occasion to wait
for the appearance of the above symptoms before attempting relief,
because we have means to subdue it without the infliction of any
immediate or permanent injury to the system, and as soon as the
evil manifests itself, we at once apply the remedy, saving the
patient a great amount of suffering, and the friends and ourselves
much anxiety and alarm. And hence, we believe our practice has
a vast advantage over that which dare not attempt certain relief
until after a lengthened period of pain and distress, and when
exhaustion of the vital forces is about to commence. Promptness
in combating this system, as well as many others, is the only
method by which to insure certainty of success.

In cases of rigidity, during the early part of labor, it will be
necessary to evacuate the contents of the rectum as well as of the
bladder ; if, after having waited for ten or fifteen minutes subse-
quently, the rigidity still remains, it may readily be overcome by
one of the following means : The compound tincture of Lobelia
and Capsicum may be given in a dose of one, two, or four flui-
drachms, according to the urgency of the case, and repeated in ten
or fifteen minutes should it be required, and in the generality of
cases, this will effect a speedy and safe relaxation. I have some-
times met with cases, in which it became necessary to administer,

DIFFICULT LABOR — FIRST STAGE.

335

in conjunction with the above, an injection of the same tincture,
employing it in the quantity of half a fluidrachm, or a fluidrachm
diluted with a similar amount of water, and requesting the patient
to retain it as long as possible. Indeed, in many instances, this
enema will be found sufficient to overcome the rigidity, without
the administration of any medicine by mouth ; and in a few
instances, where rigidity had existed for a long time, and was
rather intractable, I have subdued it, by aiding the above con-
joined means with fomentations of Stramonium leaves applied over
the abdomen and genital parts. In the first stage of labor, this
fomentation may be employed with safety. Lobelia, or some of its
compounds, has been used by various practitioners in a manner
similar to the above, and with almost universal success. The
emetic influence of this agent, in whatever combination it may
be given, is not necessary to produce the required result, nor indeed
is it always desirable that emesis should follow ; much more salu-
tary and immediate results will ensue from nauseating and relaxing
doses — and when vomiting has once occurred from its use, without
relaxation, it will frequently be found, that smaller doses will not
be retained sufficiently long upon the stomach to exert any relax-
ing influence. Lobelia has been combined with some preparation
of Opium, and administered by mouth and in enema, with success
by several physicians, but I have never employed it in this form,
although I have no doubt of its efficacy.

The tincture of Gelseminum has, within the last few years, been
recommended to overcome this difficulty, and I have administered
it in a considerable number of cases with benefit. It possesses an
advantage over Lobelia, in pot causing nausea or vomiting ; but,
as a general rule, its influence is not so readily experienced as with
that drug, and when once effected, it is of a more permanent char-
acter. Some cases will be met with, however, whose susceptibility
to its action is so great, that half a fluidrachm will produce power-
ful relaxation, while others again, may take several fluidrachms
with but little effect ; these latter instances are found only occa-
sionally, but sufficiently often for the practitioner to keep the fact
constantly before him. The dose of the tincture is from half a flui-
drachm to a fluidrachm, which may be repeated every fifteen or
thirty minutes, according to the peculiar nature and urgency of the
case. An overdose will not produce any evil effects, further than
an increase of relaxation and its greater persistency, unless the

\

336 AMERICAN ECLECTIC OBSTETRICS.

remedy be improperly continued after a full manifestation of its
influence ; the antidotes to its overaction are stimulants internally,
aqua ammonia to the nostrils, and, if required, electro-magnetism.

I would call the attention of the profession here, to an import-
ant point connected with this agent, and which is that the tincture
should always be prepared from the fresh root, and kept in well
stopped vessels ; if made from the dried root, it is useless, and
even when properly prepared, if the vessels containing it are kept
open, it loses a volatile principal, upon which its power, probably,
depends, and becomes inert. I have seen specimens, which, if
given in half-pint doses, would, I believe, produce no other effect
upon the system, than that caused by the liquor alone.

In addition to the above-named means for overcoming its relaxiug
influence, it may be stated that, a piece of Turk's Island salt (com-
mon coarse salt), about the size of a large pea, chewed and swal-
lowed, will produce a restoration in five or ten minutes, in many
instances. The late Dr. F. Hill informed me, that at one time, his
brother brought from Yicksburg, on the steamer General Pierce,
five barrels of the tincture. They were common whisky barrels,
and were placed in the hold, easy of access. Knowing the disposi-
tion of the deck hands to tap such barrels, he informed the mate,
that the contents of these were of such a nature, that he must not
allow the hands to drink it. Notwithstanding this caution, the bar-
rels were tapped, and the tincture drank for whisky, and all who
partook, were more or less affected by it. But of three men who
had partaken freely, having swallowed about a pint each, two died ;
when the doctor's brother heard of the circumstances, he immedi-
ately prescribed for the other, and saved him by the employment of
quinia and capsicum in large doses, aided by external stimulation.

In those cases where inflammation of the os uteri is caused by
unequal pressure of the child's head upon it, the Gelseminum will
be found a valuable remedy.

The induction of copious perspiration by the spirit vapor-bath,
or otherwise, has been advised, and will, probably, be found effectual
in some cases. But on account of the trouble attending its applica-
tion during parturition, and the danger of chill subsequently, it is
better to employ it only when imperatively require'd.

Inhalation of Chloroform, the direct application of extract of
Belladonna to the os uteri, artificial dilatation, etc., have all been
recommended by various writers, but I have never used them ; the

DIFFICULT LABOR — FIRST STAGE.

337

above means having proved successful in my own practice, as well
as that of others presented to my notice.*

To overcome Rigidity of the Vagina and soft parts, it may
become necessary to employ vaginal injections, or to apply fomenta-
tions to the perineum. A warm infusion of equal parts of Elm

* In relation to manual dilatation of the os uteri, which has been recommended by
some writers, under certain circumstances, it may be well for the student to acquaint
himself with the following rules, given by Prof. Dewees, which may prove serviceable
in the cases to which he alludes:

" 1st. When this part does not coincide with the direction of the uterine forces, and
the axis of the vagina. In this case, labor may become very tedious, for the want of
a correspondence of axes; I therefore attempt to establish them, as directed in cases of
obliquity of the uterus.

"But I never attempt even the slight change here spoken of, until the os uteri is
yielding, and at the same time dilated, to the size of a dollar, and the pains in pretty
full force. By this method, not the slightest violence is committed, nor is even pain
excited.

"2d. When the pains are powerfully protrusive, and the os uteri, though pretty
amply dilated, yet not sufficiently so to permit the parietal protuberances to pass
freely through it. In this case, much time and suffering are very often saved, by
running the extremity of the finger round the margin of the os uteri, and gently
stretching it. For, in many instances, if we gain an increase of half an inch in the
diameter of this part, it is all that is required, to enable the head to pass it.

"3d. When the head is detained by the anterior portion of the uterus being in
advance of it, and holding it as it were, in a sling. In this case, that portion of the
neck of the uterus, which is placed before the head, is obliged to sustain the whole f»rce
of the uterine efforts; inconsequence of which, it becomes not only severely stretched,
but it very effectually opposes the advancement of the presenting part, and gives rise
to much unnecessary delay, as well as very much augmenting the sufferings of the
patient.

"This case is one of very frequent occurrence; and women who have ample pelves,
and especially those who have had several children, and are liable to the anterior obli-
quity of the uterus, are more particularly obnoxious to it. I do not know that any
writer has noticed this cause of tedious labor; and though this can not, strictly speak-
ing, be considered as an instance of rigidity, it nevertheless has all the effects of that
condition, as it creates delay, by a portion of one of the soft parts opposing the pas-
sage of the head ; and may, therefore, with much propriety, be considered under the
present head of our subject.

"We are every way satisfied, from long observation, that this situation of the
uterus, and of the head of the child, is one of the most common causes of delay when
everything else is favorably disposed, that occurs in practioe — at least in this country.
Whether this be so in Europe, where the remote causes, namely, large pelves, are not so
general, we are unprepared to say ; but we are certain, that the frequency of this rela-
tion of the head of the child, and the anterior portion of the uterus, in this country,
render such labors more tedious, by hours, than they would be, if no such interposition
of the neck of the uterus took place.

"It is true, that the remora which the neck of the uterus offers to the passage of the
head when down before it, never of itself creates a serious difficulty; the evil chiefly

338

AMERICAN ECLECTIC OBSTETRICS.

Bark and Lobelia may be used in enema ; and the same articles
may be used as a cataplasm or fomentation. These, however, will
not always be required, as the means above recommended will gen-
erally overcome the rigidity of the soft parts as well as of the os
uteri. When the vagina is dry, harsh, and hot, warm lard oil, or

consists in a painful and unnecessary delay; but as the case is always manageable,
when it is proper to offer aid, it is certainly right to correct this deviation from a strictly
healthy labor, as early as circumstances will permit.

"The proper time to act is, when the head occupies the inferior strait and vagina,
completely ; when the pains are active ; and when the os uteri is sufficiently dilated
to permit the head to pass, if the axis of the head, and that of the os uteri, were
coincident.

"To relieve the head from this state of embarrassment, we must draw the prolapsed
edge of the os uteri by the point of the finger, in the abscence of pain, toward the sym-
physis pubis, and maintain it ihere, until a pain comes on. At this moment, the point
of the finger is to be placed against the edge of the uterus, which is to be pushed upward
between the head of the child and the pubes. Should we be able to carry the prolapsed
portion of the uterus above the advancing portion of the head, the former will suddenly
withdraw itself from the finger; the vertex will apply itself to the arch of the pubes,
and the labor terminate almost immediately.

"It sometimes, however, requires several trials of this kind before they may succeed;
but the attempt must not be abandoned because it fails a few times, for the principle is a
correct one, and should be acted upon perseveringly, should perseverance be necessary.
We have everything to gain, if we succeed, and nothing to lose if it fail; a disappoint-
ment, by-the-by, which can not well happen, if the process for the restoration of the
prolapsed part be properly conducted.

"We are convinced that we have 6een very many labors, shortened by hours, by act-
ing as just proposed for such cases. It would be extremely difficult to determine, a
priori, the duration of a labor of this kind, if left to itself; as the resistance which the
margin of the uterus offers to the head, will for a long time be more than equal to the
power of the uterine forces; consequently, the labor becomes stationary, and will con-
tinue to be so, until the margin of the uterus is obliged to yield, by its losing a part of
its power from attenuation, or perhaps by tearing.

"Nobody estimates the general rule, 'to let a labor alone that is advancing well, and
is natural in its general relations,' more highly than we do; we look upon it as a most
wholesome restraint when acted upon; and is every way calculated to diminish ignorant
and mischievous officiousness. But this rule, like every other general rule, has its
exceptions; and we may be even accused of violating it unnecessarily, when we make
the cases under consideration exceptions ; but we should feel but little concern upon
this head, if the charge be even preferred against us, as we are certain that we are
justified in making them from ample experience.

" Many, nay, perhaps everybody (for we have said that we did not know that this case
had been noticed), will condemn what we have said upon this subject, and consider our
directions as unnecessary, if not mischievous, because they have never had recourse to
them, but have permitted the uterus to perform this duty unaided; therefore they say
nature is competent to the work, and when she is competent, she is not to be interfered
with. Were this rule rigidly acted up to, there would be an end to improvement, not
only in the obstetric art, but in the whole range of practical medicine. Our experience,

DIFFICULT LABOR — FIRST STAGE.

339

lard itself warmed into a state of fluidity, may be injected with
much advantage ; but the parts should never be anointed by
friction.

Rigidity depending on disease of the os uteri, may be removed
by the above plan, but it can not always be expected to answer.
Incising the cervix has been advised as a successful measure in those
cases which prove very obstinate and protracted ; but I have never
had occasion to attempt the operation, probably, from never having
had a case of this nature.

"When the various means recommended to subdue the rigidity
fail to accomplish this result, and artificial delivery becomes neces-
sary, it is recommended to complete the labor with the forceps, pro-
vided the os is fully dilated, and the fetal head has descended so
low into the pelvic cavity that an ear can be felt. But if the os is
not fully dilated, and the greater part of the fetal head remains
above the superior strait, and circumstances present, demanding
prompt delivery in order to save the mother's life, the perforator
and crotchet must be employed, for in such instances, the attempt
to deliver by forceps would be rash and unjustifiable ; however, it
will seldom happen, unless in cases of diseased os, that the treat-
ment above-named will fail in overcoming the rigidity.

The tendency to this cause of difficult labor, as well as of ineffi-
cient uterine contractions, may generally be obviated by a proper
course of management through the gestating period, or at least
during its latter months, in all cases where the physician is aware
of his selection as the accoucheur. For a few months previous to
the expected labor, he should explain and impress upon his patient's

however, teaches us not to heed this sweeping, indiscriminate rule; for it is not sound
practice to permit nature to struggle through difficulties, merely because it is supposed
she can struggle through them; and to leave it for some time a moot point, whether or
not the case will eventuate in safety, when aid, as certain, as safe, is always at com-
mand. Nor does this application of the finger ever produce pain or other inconvenience,
if properly and gently managed.

"Beside much delay is sometimes experienced from this dropping down of the ante-
rior portion of the uterus, by interrupting the pivot-like motion of the head, from
completing itself; especially when the head occupies pretty strictly the inferior strait.
In this case, the posterior fontanelle will remain for a long time stationary behind one
of the foramina ovalia; for its advancement toward the arch of the pubes, is prevented
by the prolapsed portion of the uterus interfering with the motion just mentioned, by
embracing too strictly the advancing part of the head.

"But the pivot-like motion of the head is almost always restored, the instant we suc-
ceed in passing the depending portion of the uterus above the head of the child by the
point of the finger, as directed above."

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AMERICAN ECLECTIC OBSTETRICS.

mind, the necessity and advantages to be derived from a proper pre-
paratory course, especially, if any circumstances exist, which might
lead him to anticipate a difficult parturition. The course to be pur-
sued at this time, and which has proved generally successful, is, to
keep the bowels in a normal condition by diet, if possible, other-
wise, by mild laxatives, as Rheum and Bicarbonate of Potassa ;
avoid fatigue, over-stimulus, and improper food, and administer once
or twice daily, a dose of the compound syrup of Partridgeberry, or
of the Parturient Balm, either of which exerts a healthy tonic influ-
ence over the uterus, disposing it to act with proper energy at the
time of labor.

The proper position of the uterus is when it occupies the middle
of the abdomen, with its longitudinal diameter in the direction of
the axis of the superior strait ; but in persons of a lax and flaccid
habit of body, it frequently inclines anteriorly or laterally, which
inclination is termed OBLIQUITY OF THE UTERUS, and which
may, by producing rigidity, or other symptoms, retard labor; the
positions of the presentations are frequently affected by these
obliquities, and the deviations of which, continue, in many in-
stances, even after the uterus has been restored to its normal
situation. There are three varieties of obliquity : an anterior
obliquity, in which, from excessive relaxation of the abdominal
parietes, the fundus uteri falls forward, throwing the os uteri
upward and backward in an unusual degree; a right lateral
obliquity, in which the fundus falls toward the right side; and a
left lateral obliquity, in which it falls to the left side. Among
these the left lateral obliquity is more frequently met with. In an
anterior obliquity, the female will be very apt to imagine herself
larger than usual, or perhaps, that she will give birth to twins.
These obliquities may be ascertained by observing that the fundus
of the uterus falls to the right, or left, or anteriorly, and that the
os uteri, instead of its normal situation in the center of the
pelvic cavity, is directed laterally to the right, or left; and in
the anterior obliquity it will be found upward and backward,
elevated to an extent corresponding, relatively, with the anterior
inclination of the fundus. These obliquities, when excessive,
especially the anterior, have frequently given rise to the idea that
the os uteri was imperforate ; and if not readily recognized and
overcome, they may occasion more or less serious accidents to
both mother and child.

\

DIFFICULT LABOR — FIRST STAGE. 341

TREATMENT.— This difficulty can be removed, by placing the
patient upon the side opposed to the obliquity, or upon her back
in the anterior variety; and when this is accomplished, by applying
a bandage firmly around the body the organ may be kept in its
normal position. In the early stage of labor, it will be found
advantageous, in these cases, to keep the patient upon her back,
having the shoulders somewhat depressed, and the hips slightly
elevated. Any attempt to remove these obliquities by pulling upon
the os uteri is highly improper.

Sometimes there is an Obliquity of the Os Uteri only, and this is
more apt to procrastinate the labor, than when the whole organ is
inclined. Upon an examination, the os uteri will be found facing
the sacrum, and oftentimes being difficult to reach. Should this
condition remain for any length of time, without change, the
expulsive efforts of the uterus being necessarily directed against
the anterior part of the cervix, which occupies the open space in
the pelvis, may, by forcing the head downward, occasion a rupture
at this point.

In a case of this kind the female should be kept in bed as
much as possible, and as soon as it can be reached, the auterior lip
of the os should be hooked by a finger, brought carefully to the
center of the cavity and sustained there until one or more subse-
quent contractions, by pressing the head downward and into the
opening, will thus prevent the lip from resuming its previous
abnormal position.

Labor is occasionally protracted in consequence of the Anterior
Lip of the Os Uteri being retained between the head and pubic symphysis,
either being caught thus during the dilatation, or occasioned by an
unequal dilatation of the anterior and posterior portions of the
cervix. This may delay the first stage of labor for several hours.
It may be overcome by the following operation, provided the head
does not fill the pelvis too tightly, and the lip of the os uteri is not
cedematous from the pressure, or inflamed, in which case, it is
better to trust to the natural efforts. The operation is, to gently
push the anterior lip over the crown of the head, during the
absence of a pain, and retain it there by firm and constant pres-
sure, during one or two subsequent pains, until it retracts and
slips over the head. Not unfrequently, this operation will prove
unsuccessful, and the continued pressure of the finger upon the lip
and soft parts, will cause increased swelling and inflammation;
in the majority of cases of this kind, if the constriction of the lip

342

AMERICAN ECLECTIC OBSTETRICS.

be relieved by pressing the fetal head more toward the pelvic
cavity, or toward the sacrum, and holding it thus during a few
pains, the lip will retract without any further aid. If the project-
ing anterior lip be hypertrophied, these manipulations will prove
of no utility.

Occasionally, at the commencement of labor, the os uteri may
descend with the head, as far as, or even through the pelvic outlet;
this must be remedied by placing the patient upon her back, with
the shoulders depressed, and the hips elevated — then by gentle and
steady pressure with the expanded fingers, return the prolapsed
organ to its proper location.

As a common rule, when the os uteri becomes fully dilated, the
membranes are ruptured by the internal pressure upon them ; but
there will frequently be found exceptions to this rule. These
exceptions are owing to a RIGIDITY OR TOUGHNESS OF
THE MEMBRANES, and which render the labor protracted, by
retaining the liquor amnii, and thus hindering the uterus from
acting with energy.

TREATMENT. — In cases of this kind, the membranes should
be ruptured artificially, after which the contractions will become
stronger and more , regular. But a proper degree of caution is
required before attempting this operation, because, if prematurely
effected, it may terminate in more serious results than had no
interference taken place. In the first place, there should be good
ground for attributing the delay to this cause ; secondly, before
attempting it, the os uteri should be fully dilated and the soft parts
in a yielding condition ; and thirdly, with primiparse, it should
always, if possible, be postponed until the first stage of labor is
completed. Eeeble and inefficient contractions for several hours,
with softness and dilatability of the parts, and the labor having
nearly or fully terminated its first stage, are among the symptoms
indicating an artificial rupture. It is sometimes difficult to effect
a rupture of the membranes, especially when the pains are feeble,
and the use of a probe or sharpened quill has been recommended ;
I have always succeeded with the finger nail, pressing it upon the
membranes during the pain, and making a sawing motion with it
from before backward, or from side to side, and continuing it until
the liquor amnii escapes.

The dilatation of the os uteri is aided materially in its progress by

DIFFICULT LABOR — FIRST STAGE. 343

the mechanical, wedge-like pressure of the bag of waters; but when
the MEMBRANES HAVE RUPTURED PREMATURELY,
this bag is absent, the fetal head then presses upon the os uteri,
but is illy adapted to aid its dilatation, and the result is a tedious
labor. The premature rupture may be owing to a weakness of the
membranes, to violence, or to a careless examinatiou, and which
last is perhaps a more frequent occurrence, than is generally imag-
ined. An early rupture of the membranes is also an indication
of a preternatural presentation, and whenever it occurs, the char-
acter of the presentation should be determined as soon as possible,
that timely measures may be adopted, if required. When the
membranes are prematurely ruptured, the liquor amnii may be dis-
charged in a very short time, or if the rent be small, or the fetal
head lies over its orifice, this fluid may slowly dribble away, and
add much to the discomfort of the patient.

TREATMENT. — If the os uteri is dilatable, and the pains are
active, nothing is required but a little patience, as the labor will
usually proceed with safety to both mother and child. If, how-
ever, the os uteri be rigid and unyielding, this condition must be
overcome by the means already mentioned on page 334. If the
liquor amnii passes off slowly, the os being dilatable, and the pains
feeble, the orifice in the membranes should be enlarged, and the
fetal head elevated, between the pains, toward the sacrum, in
order to admit of a free discharge of the liquor, and which will
be followed by active contractions. The dilatability of the os may
be increased by the tincture of Gelsemiuum administered inter-
nally, or by a rectal enema of the compound tincture of Lobelia
and Capsicum.

In closing this chapter on the causes which may protract the
first stage of labor, I desire to impress upon the mind of the stu-
dent, that the mere fact of the tediousness of this stage does not
justify any attempts to hasten the labor. Delay in this stage sel-
dom causes any serious accident to either the mother or child,
unless, from a want of patience and prudence, it be unnecessarily
or improperly interfered with. True, the female may become
worn out or exhausted, but this is soon removed by an energetic
uterine action in the second stage, and in which stage only, is the
shock given to the nervous system which may produce unpleasant
or serious results. He should, therefore, be very cautious and
particular in ascertaining that artificial assistance is positively
required, before attempting to render it; always bearing in mind

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the wholesome and oft-repeated saying of Blundell, that "a med-
dlesome midwifery is bad." (See quotation of Dr. Washington's
method of inducing uterine contractions, and dilatation of the
os uteri, in the subsequent chapter.)

CHAPTER XXIX.

DIFFICULT LABOR. — SECOND STAGE.

The SECOND STAGE OF LABOR may be protracted, even
when the first has progressed favorably, and may be owing to
causes not necessarily nor immediately connected with the first
stage, or which, although present in that stage, can not be deter-
mined until the complete dilatation of the os uteri, and which
causes, I shall consequently consider under this head.

As before remarked, although labor may be delayed for a long
time during its first stage, without any hazard to the mother
or child, yet such is not the case in the second stage, for any pro-
crastination beyond a certain period is fraught with serious conse-
quences to both. The development of bad symptoms may not take
place for some hours after the commencement of the second stage,
or they may occur within six or eight hours ; and, as a general
rule, if this stage of labor has continued for twelve or fifteen hours,
symptoms of constitutional suffering will manifest themselves.
The pains, after having continued regular and forcible for a time,
gradually become more and more feeble, occurring at less regular
intervals, and causing little or no advance of the head. They
may return only at long intervals, or the intervals may be alter-
nately short and long, or they may be regular, the pains gradually
diminishing in force, until they are scarcely felt. Or, the pains
may commence each time of their occurrence, with energy, but
subside, almost suddenly, before they have reached their maxi-
mum development; or they may cease entirely.

This impaired condition of uterine action, is very frequently
accompanied with several unpleasant symptoms, varying in degree :
as, severe shiverings, frequently resembling light convulsive attacks;
distressing and frequent vomitings, of green, or bilious matter ;
restlessness and uneasiness of the patient ; the skin may be dry or
moist, but in either case it is hot; increase of pulse, ranging from

DIFFICULT LABOR — SECOND STAGE.

345

100 to 140; the tongue dry and furred, with sordes about the teeth ;
the mind despondent, disturbed, and fearful ; the vagina hot, and
with the os uteri, tender to the touch ; the mucous discharge from
the vagina becomes brown or yellowish, and occasionally fetid or
acrid ; and urination is rendered difficult, or altogether prevented
by the pressure of the fetal head. These symptoms usually occur
in the order just given, and in all cases of prolonged second stage,
some of them will be present. If relief be not afforded, they
increase in severity; the vomiting occurs more frequently, with
ejection of dark-colored matters; restlessness increases, with obsti-
nate hiccough; the abdomeD becomes tender; the skin covered
with a cold, clammy sweat ; the pulse rapid and feeble ; the tongue
dry and brown ; stupor and low-muttering delirium ensues, and
death terminates the scene. Not only is the life of the mother
endangered in such cases, but also that of the child, by the delay
of proper interference.

One of the most common causes of delay in the second stage, is a
CESSATION, OR INEFFICIENCY OF THE UTERINE CON-
TRACTIONS. As may have been observed in the previous
chapter, this is also a cause of prolonged first stage, but its effects
are by no means so grave in that stage. It may be owing to dis-
ease sudden and violent emotions of the mind, tumors, constitutional
debility, etc. Females of an irritable, nervous temperament, may
have labor protracted, during its second stage, from this cause ;
and those of debilitated constitution, frequently have a failure of
uterine action in this stage, and especially, when from prolonga-
tion of the first stage, great exhaustion occur.

TREATMENT.— When attending a case in which the action of
the uterus becomes lessened, the pains short and inefficient, or at
long intervals, with no advance of the fetal head ; increased and
irregular pulse, restlessness, anxiety, and wakefulness being also
present, it will become necessary for the practitioner to institute a
very minute and careful examination not only of the genital
organs, but likewise of the condition of the tongue, pulse, skin,
head and abdomen. By the examination of the genital organs he
will ascertain, if possible, the cause of the delay, and determine by
it the best method of affording assistance ; and by the condition
of these parts, in connection with the general con dition of the sys-
tem, he will be guided as to the proper time for interference.

The cause of the delay can, of course, be learned only from the
23

346 AMERICAN ECLECTIC OBSTETRICS.

examination. The best method of affording assistance, is, invariably,
that which terminates the labor most easily, and with the least
danger to the mother and child. Among these means may be
named, Ergot, the Vectis, the Forceps, and the Crotchet ; each of
which will be considered hereafter. The proper time for interference,
will depend entirely upon the symptoms ; an increase of the pulse,
febrile symptoms, soreness and tension of the abdomen ; exhaus-
tion ; watchfulness, and anxiety ; a dry, hot, puffy, or swollen con-
dition of the soft parts, caused by the long-continued pressure and
interrupted circulation, and accompanied with a degree of tender-
ness which renders a vaginal examination painful; a retention of
urine, from pressure of the fetal head on the urethra and neck of
the bladder, requiring the use of the catheter, which can be intro-
duced only with difficulty; and a change in the character of the
vaginal discharges, they becoming offensive — are all symptoms
requiring immediate delivery. Indeed, as a general rule, it is
good practice to interfere, even before the local symptoms have
appeared.

If, in cases of protracted labor from rigidity, the constitutional
disturbance is excessive, with exhaustion of the vital forces, and
determination of blood to particular organs, especially the brain,
the prognosis is very unfavorable. Fever, in either stage of labor,
manifested by chills, increased pulse, furred tongue, and flushed
countenance, indicates the want of artificial aid ; and the case
assumes a still more serious aspect, if the pains gradually lessen in
frequency and power, the fetal head ceasing to advance, and the
female becoming exhausted. Sometimes, these symptoms come
on very suddenly, requiring an immediate interference ; the pains
cease, the mind becomes confused and wandering, a clammy per-
spiration covers the face and body, restlessness with constant hic-
cough occurs, and the patient becomes so completely changed in
features and in tone of voice, as to be hardly recognized by her
friends.

These symptoms may occur during the first stage, but they will be
more frequently met with in the second stage, where the head has
passed through the os uteri into the pelvic cavity, and has been
pressing for a considerable time upon the parts at the inferior strait.

It is frequently the case that the contractile power of the uterus
is so readily exhausted, that after having effected the first stage of
labor, the pains cease, or become very feeble in the second. In
these instances the pelvic diameters will be sufficiently ample, the

DIFFICULT LABOK — SECOND STAGE.

347

soft parts in a yielding condition, and the head, in whatever por-
tion of the cavity it may be, will be found in a normal position.
In such cases, the female should have a bandage placed around the
abdomen, sufficiently tight to make some pressure upon the
uterus, and should frequently change her position, sitting, lying
down, and walking about the chamber, alternately ; Caulophyllin
or Cimicifugin should likewise be administered in doses of two or
three grains every fifteen, or thirty minutes ; and if these fail, and
symptoms of exhaustion manifest themselves, it will then be
proper to administer Ergot. And, indeed, this course may be
pursued in all cases of inefficient uterine contraction, owing to
mere debility or exhaustion of the organ. Notwithstanding that
Ergot has been so frequently employed to facilitate labor, with no
apparent immediate pernicious results, yet the practitioner should
ever bear in mind, that it is a dangerous remedy at best, requiring
much judgment and discrimination in its employment. The
dangers attending its use, to the mother, are, rupture of the
uterus, rupture of the perineum, inversion of the uterus, etc., to
the child, death, and more certainly if the cord is around its neck.
And, although it has been employed with impunity, in many cases,
where the only indication for its use was the impatience of the
practitioner — a regard to his own comfort and feelings, in prefer-
ence to the safety of his patient — still, it is an agent whose action
is always to be dreaded : and the success attending its administra-
tion in the instances just referred to have been the results of good
luck, and not of any superior skill or wisdom of its prescribers.

Ergot has, undoubtedly, a specific action upon the uterus, which
usually commences within twenty or thirty minutes after its exhi-
bition ; and the character of the contractions produced by it are
materially different from those of natural labor. They are
stronger and of longer duration, resembling a number of violent
or spasmodic uterine contractions continued into one another
without intervals. During a contraction, the circulation of the
maternal blood in the uterus and placenta must be interrupted;
and when this interruption occurs for a* long-continued time, as
when effected by ergotic influence, preventing the necessary
changes in the fetal blood, we should anticipate unfavorable results
to the child, and not be unexpectedly astonished upon finding it
born in an asphyxiated condition.

As it is not uncommon to meet with individuals whose constitu-
tions are insusceptible to the specific influences of one or more

48

AMERICAN ECLECTIC OBSTETRICS.

drugs, so must we expect to meet with females upon whom Ergot
exerts but little or none of its peculiar action ; and this want of
susceptibility may account for many of the failures which have been
recorded by authors. Another cause of failure has been, undoubt-
edly, the want of a recent article ; for Ergot, especially when in
powder, rapidly loses its property of exciting uterine action by
keeping ; and, no matter how carefully it may have been preserved,
it is very apt to become worthless in one or two years. The best
mode of preserving it, is to dry it quickly in the sun, or by artificial
heat, and then place it, unpulverized, in well-corked vials, into
which a few lumps of camphor should be deposited. These
should be kept in a dark situation, and where the temperature is
rather constant, ranging between 50 and 80 deg. Fahrenheit. It
should be pulverized only when required for use. Good Ergot, when
pulverized, has an odor somewhat resembling that of new-mown
hay ; when of inferior quality, it has a musty smell. It is usually
given, during parturition, in infusion or tincture. The infusion is
of a dingy violet color, and the tincture of a dark reddish-brown.
The ethereal oil has likewise been administered with good effect.

In the administration of Ergot to females during parturition,
there are certain rules to be guided by, which are based upon the
recorded experience and observation of many medical men, and
which should be thoroughly impressed upon the mind of every
individual who attempts the conduct of a labor; they are briefly
as follows :

Ergot should never be given for the relief or comfort of the prac-
titioner; where any deformity of the pelvis is suspected; where the
head is suspected to be disproportionately large ; where the pre-
sentation is beyond reach, or can not be determined ; where there
exists an obstruction in the soft parts, as rigidity, etc. ; where
there is a mal-presentation ; where there exists increased excite-
ment of the nervous or vascular system ; where there is a tendency
to cerebral symptoms ; and where the os uteri is not fully dilated.
It should never be given while the woman's strength is greatly
exhausted, lest the exhaustion produced by it be more excessive
than her system can bear.

Ergot should be avoided, as much as possible, in first labors, lest
rupture of the perineum ensue.

Ergot may be given, in careful hands — in multiparas, where the
sole cause of delay is deficient uterine contraction ; where the head
presents and is low in the pelvis, the os uteri soft and fully dilated,

DIFFICULT LABOR — SECOND STAGE.

349

the soft parts yielding and dilatable, and the membranes have
ruptured ; and the pelvis must be ample, with normal proportions
between it and the fetal head. The patient must also be somewhat
exhausted, but without any symptoms of fever or inflammation.

Many authors recommend the administration of twenty or thirty
grains of Ergot in powder, or infusion, for a single dose ; but in
my own practice, in all cases where I have considered its use indi-
cated and advisable, I have succeeded in arousing the contractions
of the uterus, in fifteen or thirty minutes, by the following course :
To about four fluidounces of Boiliug Hot Water, add one or two
drachms of good Ergot, in coarse powder, and when this is suffi-
ciently cool, tablespoonful doses of the infusion are given every five
or ten minutes. Should the tincture be preferred to the infusion,
it may be exhibited in doses of half a fluidrachm or a fluidrachm,
every ten or fifteen minutes : the dose of the oil is from ten to
thirty drops in water, tea, or some aromatized syrup, and which
may be repeated every fifteen, twenty, or thirty minutes.

I would remark here, however, that among those practitioners
who are acquainted with the parturient virtues of Cimicifugin and
Caulophyllin, or even of the crude roots from which these agents
are obtained, the employment of Ergot for the purpose of inducing
(spasmodic) contractions of the uterus, is very seldom required.
And it is always advisable, in the cases under consideration, to
give these agents a fair trial before resorting to the ergotic prepar-
ations; more especially as they may be exhibited with greater
safety, and at an earlier period of labor; beside, the contractions
they induce bear a greater resemblance to those caused solely by
the natural powers.

It will sometimes be found, that although the contractions of
the uterus may be aroused by the administration of Ergot, they
are not of an expulsive character; in such cases the uterus con-
tracts firmly upon the part of the child within it, preventing its
advance, and causing its death by the pressure maintained around
it, unless timely assistance be afforded by the employment of the
forceps. Hence, it is recommended by our best accoucheurs, to
have a forceps at hand, when this drug is exhibited. It must
be recollected, however, that so long as the pains continue, with
an advance of the head, however slowly, the pulse continuing good,
no trouble in urinating, and no pain of the abdomen on pres-
sure, ARTIFICIAL INTERFERENCE IS NOT REQUIRED ; but ill debilitated

patients, in whom symptoms of exhaustion and fever appear,

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AMERICAN ECLECTIC OBSTETRICS.

interference will be demanded, even though the head be very
slowly advancing. And by delaying the necessary aid, the patient
may die after delivery, from the shock of the labor, or from hem-
orrhage and retained placenta or, should life be spared, sloughing
of the uterus, vagina, bladder, and rectum may take place, ren-
dering her subsequent existence painful and burdensome in the
extreme.

Sometimes, the second stage of labor may be prolonged by
RIGIDITY OF THE SOFT PARTS, especially of the perineum.
In such cases a resort to Ergot, or the forceps, while the rigidity
remains, is highly censurable. Occasionally, during the advance
of the fetal head, the os uteri, instead of yielding, grasps the head
during each pain, and prevents its further progress; this is apt
to alarm the practitioner, who, having ascertained that the position
of the head is correct, finds it to remain stationary, notwithstand
ing pain after pain continues with much force and severity. A
careful examination, as to the presentation and position of the
head, and its relative proportions with the pelvic diameters, may
determine the cause of the delay. The same cause frequently pre-
vents the head from rotating.

TREATMENT. — Patience is required in these cases, in conjunc-
tion with the means named for overcoming rigidity, in the previous
Chapter. In the instance of rigid os delaying the advance of the
fetal head, it will always be proper to correct any abnormal posi-
tion of the uterus which may be present, so that its longitudinal
axis may correspond with the axis of the superior strait.

The following abstract is taken from Braithwaite's Retrospect,
part 28, for January 1854, p. 273:

"Dr. "Washington has recently discovered that dry-cupping,
applied to the lowest part of the sacrum, produces dilatation of the
os uteri ; and, applied higher up, contraction of the uterus. In
a case, where the pains had endured fourteen hours without pro-
ducing any perceptible effect, in consequence of rigidity of the
os uteri, Dr. Washington applied a dry cup as low down on the
sacrum as possible, so as to cover the origin of the nerves to the
os uteri. Complete relaxation ensued; at the next pain, the head
descended to the outlet ; and at the second pain the patient was
safely delivered; and that in less than ten minutes from the appli-
cation of the cups. In tedious labor, the cup should be applied
first to the lowest point of the sacrum, and if, in the course of ten
or fifteen minutes, the patient is not delivered, another should be

DIFFICULT LABOR — SECOND STAGE.

351

applied higher up, so as to cause the uterus to contract. The lower
one should always be on when the upper one is applied, so as to insure
relaxation of the os uteri when the pains come on.

" In retained placenta, the cups are to be applied higher up, so
as to cause the uterus to contract at once, the relaxation of the
os uteri being always sufficient after the fetus has passed. When
Ergot is administered, the woman is delivered by main force, with-
out any relaxation except that produced by the most fearful pains.
By dry-cupping, two or three pains are sufficient, and the amount
of suffering is not more than ordinary.'' — Association Med. Journal,
May 27, 1853, p. 469. ' %

Should the method named in this statement be found generally
efficacious, the discovery will prove a great blessing to parturient
females in several other respects, and the Science of Obstetrics
will be deeply indebted to its discoverer. It is simple and safe,
and is certainly deserving a trial in all protracted labors from
rigidity of the os, or debility of the uterus, before resorting to the
administration of Ergot.

SHORTNESS OF THE UMBILICAL CORD, may be a cause
of protracted labor. It may be very short, naturally, not exceed-
ing six or seven inches in length, so that it becomes torn as the
trunk and inferior extremities are expelled, or its ligation and
division may be required before these can be extracted. Most
commonly, however, the shortness of the cord is accidental,
occasioned by its being twisted several times round the neck or
body of the fetus. The delay in the progress of the labor may be
suspected to depend upon this difficulty, when in either stage of
labor, the head not only retracts upon the subsidence of the pain,
but does not advance with the usual force when the pain is
present; sometimes the cord may be so shortened, and the head held
up so high, as to prevent the practitioner from ascertaining the
presenting part until the commencement of the second stage.
Should the placenta be attached to some portion of the uterine
cavity, near the neck, instead of toward the fundus, the above
symptoms will be absent, and the diagnosis will be very obscure.
But to whatever part it may be attached, a sensation of dragging,
or tearing, with pain, will be experienced by the patient during
the expulsive contractions, whenever the cord is shortened.

Should the case be suspected a shoulder presentation, from the
fact that at the full dilatation of the os uteri, the presenting part

352

AMERICAN ECLECTIC OBSTERICS.

can not be felt, the practitioner may be induced to attempt turning,
but the introduction of the hand within the uterine cavity, at once
ascertains the presentation of the head retained by a short cord.
When, in the second stage, the head presents in a proper position,
and is of normal size, the soft parts being free from any rigidity,
the head in any part of the pelvic cavity, and the pains regular,
shortness of the cord may be suspected when the head is found to
recede very much with the cessation of the pains, and making no
further advance when they are on, for several hours in succession.
If two fingers, or even the whole hand, be passed up as high as
possible, between the head and symphysis pubis, the diagnosis will
be positive, upon feeling the cord passing around the neck.

TREATMENT.— If the pulsations in the cord be strong and
vigorous, the best practice is to have patience, and leave the case
to nature. If the pulsations are feeble, or gradually becoming so,
we are recommended by Dr. Lee to deliver immediately with the
forceps, and to carefully abstain from the use of Ergot. To
attempt turning, in such a case, would be downright stupidity.

Prof. Meigs recommends loosening the cord by pulling upon its
yielding end, and endeavoring to cast it oft' over the head.
"This," he says, "can not always be done; if so, in any case, let
the child pass through it by slipping it down along its body over
the shoulders. If it seems impossible to slip the cord over the
head or shoulders either, it should be let alone ; and in a great
majority of cases it will not prevent the birth from taking place,
after which, the cord can be cast off. Should the child seem to be
detained by the tightness of the cord, as does rarely happen, or in
danger from the compression of its jugular vessels, the funis may
be cut with the scissors, aud tied after the delivery. Under such
a necessity as this, a due respect for one's own reputation should
induce him to explain to the bystanders the reasons which ren-
dered so considerable a departure from the ordinary practice
indispensable." It is not always, however, that the cord can be
reached, at least so as to pull it down, or otherwise operate upon
it, and in such instances, we must expect the means recommended
by Prof. M. to be impracticable. Should the child be dead, as
ascertained by absence of the beating of the fetal heart, and the
cessation of pulsation in the cord, the labor should not be inter-
fered with.

Occasionally, HYDROCEPHALUS in the fetus is a cause of

DIFFICULT LABOR — SECOND STAGE.

353

difficult labor ; in which case, notwithstanding the dilatable con-
dition of the os uteri, the head remains above the superior strait,
and if the cause be not early ascertained, exhaustion, or rupture
of the uterus ensues. The danger is in proportion to the size of the
child's head; where the effusion is inconsiderable, the soft and
flexible condition of the head may admit of its delivery, by
gradually adapting it to the canal through which it has to pass,
and lengthening its long diameter very considerably. But when
the effusion is abundant, and the diameters of the head exceed
those of the pelvis so much as to render delivery impossible, inter-
ference will be demanded. If a dropsical head be allowed to
remain for any time impacted in the pelvic cavity, the continued
pressure it exerts upon the soft parts would be very apt to produce
sloughing; and in nearly all those cases, where the cause of the
delay has not been easily ascertained, a fatal result has followed to
both the mother and child.

A hydrocephalic head may be detected by the extraordinary size
of the head, and the great separation of its bones, by which the
sutures are enlarged to the size of a finger, or more in breadth, and
the fontanelles being also augmented, at times, to an extent equal
to the hollow of the hand. And, likewise, during the intervals
between the pains, a sense of fluctuation will be perceived in some
places, though this sensation may not frequently be observed, owing
to the great compression 'the head undergoes.

TREATMENT. — But one course is to be pursued in a difficulty
of this kind, when we are certain that the head can not be delivered
naturally, or without endangering sloughing of the maternal soft
parts, and when we are also positive that hydrocephalus is present.
The necessity for being enabled to detect presenting parts, as well
as their condition, is fully shown in a case of hydrocephalus ; for
should a careless or ignorant practitioner neglect to ascertain the
positive conditions present in a difficult labor owing to this cause,
and administer ergot, or other agents, to excite energetic contrac-
tions of the uterus, he would be very apt to occasion a rupture of
this organ ; or should the head be expelled, it would be at the
hazard of the mother's life, from sloughing.

In hydrocephalus, where the head can not be delivered by the
natural powers, the best chance for the mother's safety is, to evac-
uate the effused fluid by puncturiug with the perforator at an early
period, while she has sufficient strength and vigor to withstand
the shock ; if the operation be delayed too long, she may die from

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AMERICAN ECLECTIC OBSTETRICS.

rupture of the uterus, or from exhaustion. After the evacuation
of the fluid, the collapse of the bones will permit the labor to be
terminated by the uterine contractions aloue ; and if these fail,
means may be employed to excite them into greater activity, or the
forceps may be demanded. Hydrocephalus is not always readily
detected during labor, and when it is, the discovery is usually too
late for the mother to derive any advantage from it, as it most
always terminates fatally.

Should the case be one of pelvic presentation, and the head
delayed from disproportion, the perforation must be made behind
the ears.

Sometimes Ascites, or Dropsy of the Abdomen, may prevent the
body of the child from being expelled ; or this may occur from
Tympanitis, or a Distension of the Abdomen with air; in these cases,
the perforator must be thrust into the child's body, and the air or
fluid evacuated.

Labor may be rendered difficult by VAGINAL VESICOCELE,
or VAGINAL CYSTOCELE, in which the urinary bladder falls
from its proper position in front of the uterus, and descends below
the fetal head, overlapping the pelvic brim. The head, in its
descent, pushes the fundus of the bladder before it into the excava-
tion, forming a tumor of greater or less size at the anterior-superior
part of the vagina, and which, if not timely relieved, may terminate
very seriously. Sometimes the depressed bladder has been found
directed to one side of the pelvis. The patient experiences a sen-
sation of weight or fullness in the pelvis, a dragging sensation
about the umbilicus, with a constant, but ineffectual desire to
urinate ; though, a small quantity of urine may pass during each
uterine contraction. On an examination per vaginam, the finger
detects a more or less oval tumor, usually in front of the pelvis,
which is smooth, soft and fluctuating during the intervals between
the pains, but hard and tense while they are on, and painful on being
steadily pressed. The head of the child is only partially covered
by it, and may be felt by passing the finger above and behind it ;
but any attempt to slip the finger between the tumor and the sym-
physis pubis, will prove unsuccessful. Some care will be required
lest it be mistaken for the bag of waters, or a hydrocephalic head,
and improperly punctured.

TREATMENT.— This difficulty, whenever met with, must be
promptly remedied. A male elastic catheter should be introduced

DIFFICULT LABOR — SECOND STAGE.

355

into the bladder, having its point directed backward and down-
ward, and to facilitate its introduction, the head may be slightly
elevated with one or two fingers ; the whole operation must be
done during the absence of a contraction, and it may be effected
more readily by entering the point of the catheter, with the hand
below the vagina, and as it passes on toward the bladder, gradually
raising the hand. After the urine has been withdrawn, the blad-
der must be pushed upward, by one or two fingers, above the top
of the pubes, and held there till a pain thrusts the presenting part
of the child below it. Should it be impossible to introduce the
catheter, attempts must be made, during the intervals, to press up
the head, and at the same time also press up the tumor, when,
frequently, the urine will be discharged without the aid of a
catheter. If these attempts fail, and the progress of the labor is
checked by the tumor, or a rupture of the bladder is feared, from
its over-distension and from the pressure, the only resource is to
puncture the presenting inferior surface of the bladder with a
very fine trocar, having a consultation previously, if possible, with
some skillful physician. In these cases, the patient should be
carefully watched after delivery, evacuating the bladder at once,
and not allowing it, for some days, to become distended, to any
extent, with urine.

As these instances are more apt to occur in the first stage of
labor, and when the bladder is more or less filled with urine, the
necessity for keeping the bladder evacuated at such a time, will be
readily seen. It may be proper to observe here, that no tumor in
the pelvis, especially those presenting fluctuation, should ever be
punctured, without having first employed the catheter, to ascertain
that it is not vesical.

' Very rarely, a CALCULUS IN THE BLADDER may prove
an obstacle to the labor, by projecting backward, and then pressed
downward by the head, thus seriously bruising the bladder. It is
not always easy to diagnosticate this difficulty ; it will present as a
hard tumor of greater or lesser size, circumscribed, painful on
pressure, whether of the finger or child's head; and the diagnosis
may be still further verified by the introduction of a sound or
catheter into the bladder. Relief may be attempted, if the head
has not descended too far, by pushing it up above the strait, and
then pressing the calculus upward and anteriorly. If, from any
cause, this can not be effected, vaginal lithotomy, with the consent
of counsel, is advised.

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COLLECTION" OF FECES IN THE RECTUM, may inter-
pose as an obstacle to the passage of the head. These form a
rather hard, irregular, inelastic tumor, which will be felt in the sit-
uation of the rectum, and which when pressed upon, downward,
will slowly yield and cause the escape of feces. An examina-
tion per anum will at once detect the hardened scybalse. This con-
dition seldom happens except among careless and inattentive
females, and a proper attention to the condition of the bowels at
the early stage of labor, by the practitioner, will prevent its
occurrence.

TREATMENT.— The feces should be removed by injections of
warm water ; or, should they be so hard and compact as to resist
this method, it will then become necessary to remove as much as
possible, by a scoop, spatula, or the handle of a spoon, after which
administer an injection of warm water.

A portion of intestine may become engaged in the cut de sac
between the rectum and the posterior wall of the vagina, and form
a tumor of variable size. This VAGINAL HERNIA, especially
when it contains fecal matter, opposes the descent of the head, and,
from the pressure of the head upon it, may terminate in serious
inflammation, and even gangrene.

TREATMENT.— The hernia must be reduced as promptly as
possible ; the woman must be placed on her knees and elbows, with
the hips elevated, and the intestine returned by pressure with two
or three fingers. In some cases it may be necessary to relax the
system by means of Grelseminum, when the patient will lie upon her
back, with the thighs flexed upon the abdomen, and supported there
by assistants, while the reduction is attempted. If the reduction
can not be accomplished, the labor may readily be terminated by the
forceps if required.

IMPERFORATE or UNRUPTURED HYMEN, may prevent
the passage of the head. Impregnation may be effected without
lacerating the hymen, which will be found perfect at the period of
labor. It usually yields to the pressure of the head, but should it
resist for too long a time, a slight incision may be made into it by
the scalpel, taking care to prevent the laceration from extending
into the perineum, as the head passes through the external orifice,
by giving careful support to the perineum.

t

DIFFICULT LABOR — SECOND STAGE. 357

Where, from a continued DELAY OF THE CHILD'S HEAD in
the Pelvic Cavity, the circulation of the parts becomes interrupted,
the soft parts are apt to swell, thereby offering still greater opposi-
tion to the advance of the head, and which may terminate in some
structural lesion of the parts, if prompt and energetic measures be
not adopted. Dr. Campbell observes, " Unless a practitioner has
had the management of the patient from the commencement of
labor, he is apt to view this variety of diminished capacity, as
arising from original defect in the development of the bones
themselves."

TREATMENT. — This condition may be overcome, to a great
extent, by emollient vaginal injections, or injections of warm lard
or oil, either alone, or previously boiled with the flowers of St.
Johns-wort ; and if necessary, relaxation may be produced by the
administration of Gelseminum or Lobelia. Should the pains be
feeble, labor may be facilitated by an injection into the rectum of
compound tincture of Lobelia and Capsicum, slightly diluted with
water; or Cimicifugin, Ergot, etc., may be exhibited according to
the directions heretofore given, when treating of inefficient action
of the uterus. The forceps have been advised, but I should, in
these instances, fear some injury to the parts from their employment.
I have frequently given the Gelseminum to cause relaxation, and
when produced, have followed it with tincture of Ergot, with the
happiest results, in cases requiring an expeditious delivery, where
the pains were feeble, with a degree of rigidity or tumefaction of
the soft, parts.

(EDEMA OF THE LABIA MAJORA, is sometimes so great
at the time of labor, as nearly to obliterate the vaginal entrance,
rendering the delivery difficult and very painful ; and the pressure
of the fetal head in its passage over the tumefied parts, may cause
an extensive rupture, or produce gangrene. The same treatment
may be pursued as in the preceding instance, but, if the tumefaction
be very excessive, or the labor considerably advanced, it is recom-
mended to puncture the engorged parts with the lancet, in different
places, the number of punctures depending on the extent and degree
of oedema.

A CICATRIX IN THE VAGINA., will sometimes be met
with, which will present an impediment to the delivery ; it is usu-
ally the result of sloughing effected in a previous tedious labor,

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in which, the healing of the ulcer which remains after the separa-
tion of the slough, occasions a diminution of the diameters of the
vaginal canal. An examination will detect, at some portion of the
vaginal wall, a firm, unyielding band, which may occupy from
three to six lines longitudinally, or which may present merely
a very thin edge, the thickness of a wafer. The difficulty will,
of course, be proportioned to the firmness and extent of the cicatrix.

TREATMENT. — In these cases we should not interfere prema-
turely, but always wait and learn what the natural efforts can do ;
strong and energetic contractions, with the pressure of the
fetal head, may overcome the difficulty. But where assistance
is required, relaxation, effected by the compound tincture of
Lobelia and Capsicum, administered by mouth, and by rectal
enema, with applications within the vagina over the constricted
part, of Elm and Lobelia in fomentation or injection, will usually
produce the desired dilatability, and the head will advance without
any further delay. "Where the cicatrix is of great extent, and very
firm and unyielding, it is advised by excellent authority to slightly
incise the edges of the constricted part in three or four places,
being careful to avoid the neck of the bladder, the rectum, and the
two uterine arteries, which pass up from below on each side of the
vagina; and for this purpose the incisions should be made one
behind each groin, and one toward each sacro-iliac symphysis.
The least snip is sufficient, as the advance of the head will proba-
bly widen it. After the delivery, a sponge or bougie, well oiled,
should be introduced into the canal and changed two or three
times a day, so that as the part heals, the diameters of the vagina
do not again become lessened. The artificial increase of the vagi-
nal passage by incisions, should be attempted with great care, and
under the advice of counsel, for, however slight the operation may
be, the advance of the head may cause the cut to widen and pro-
duce a much more extensive laceration than if the case had been
left to the natural powers. Indeed, I am somewhat inclined to
believe that the operation will very rarely be found necessary,
where the previously-named treatment has been faithfully pursued.
Sometimes considerable hemorrhage follows, and cases have occa-
sionally terminated fatally. If the contractions of the uterus
become inefficient, or unfavorable symptoms present themselves,
the labor may demand a prompt termination by instruments, the
use of which, in such cases, even with the greatest care, is apt
to produce more or less extensive lacerations, and which are not

DIFFICULT LABOR — SECOND STAGE.

359

without danger ; and a knowledge of this fact may lead to the
practice of patience and caution.

Where the practitioner is aware of this difficulty at an early
period during gestation, or has reasons to suspect it, it is proper
for him to explain the matter to his patient, and request an exam-
ination, when if the constriction be found very great, he may
induce premature labor, and thereby save the m6ther/ the hazards
that she would run at full period; and the same course may be
pursued with females known to be laboring under Cancer of the
Os Uteri. In this latter condition of the cervix, at full term, when
the labor is delayed thereby, it may become necessary to divide
the diseased part sufficiently to admit the passage of the child.
But, as this operation is only to be attempted for the child's safety,
we must be certain that it is alive before performing it; the death
of the mother is to be expected in such cases, no matter what
course is pursued. Cauliflower Excrescence may be similarly man-
aged.

Very rarely, the labor is interfered with by an IMPERFORATE
OS UTERI, which may be suspected, when the pains are regular,
increasing gradually in force, pushing the lower segment of the
uterus into the cavity of the pelvis, rendering it very thin, without
any opening of the os uteri being discoverable.

There may be an Agglutination of the Os Uteri, the result of some
previous inflammation of the part, and which may be detected by
finding an indentation, or depressed fold at the center of the
os uteri, without any opening; the pains will be regular, increasing
gradually in force, pushing the lower segment of the uterus into
the cavity of the pelvis, rendering it extremely thin ; or the Os
Uteri may be obliterated. These conditions, are, however, rarely
met with.

TREATMENT.— It may be that the os uteri is merely rigid
and not dilatable, and the means recommended for this difficulty
may be pursued, whenever the os can be discovered. Sometimes
the os uteri is closed by agglutination, resisting the most powerful
uterine contractions ; in such instances, Dr. Rigby remarks, "A
moderate degree of pressure against it while in a state of strong
distension, either by the tip of the finger or a female catheter,
is quite sufficient to overcome it; little or no pain is produced, and
the appearance of a slight discharge of blood will show that the
stricture has given way."

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If no opening, however, can be found, it will become necessary
to divide the presenting wall of the uterus, and form an artificial
os uteri, through which the child may pass. A crucial incision is
to be made upon the anterior-inferior part of the wall, as near the
situation of os uteri as possible, by means of a sharp-pointed bis-
toury; this knife is carefully passed along the left fore-finger as a
guide, and must not be pushed too deeply into the uterine wall, lest
the presenting part of the fetus be injured. In performing the
antero-posterior incision, care must be taken not to extend it so far,
either forward or backward, as to injure the bladder or rectum.
After the operation, the delivery may be left to the natural efforts.

It must be recollected, however, that it is frequently the case,
that from uterine anterior obliquity the os uteri will be high up,
perhaps entirely beyond the reach of the finger, and looking toward
the promontory of the sacrum, and in which position it may remain
for several hours, retarding the progress of the labor. And a care-
ful search should always be instituted previous to attempting any
operation. If it be found thus elevated and inclined, the labor may
be expedited by drawing it downward and forward with one or
two fingers, in the direction of the axis of the superior strait, and
holding it there until the engagement of the head will prevent a
return to its former inclination.

Sometimes the orifice of the os uteri will be found so minute or
contracted, from disease or other causes, that the head can not pass
through it, even when dilated ; for which the same course must
be pursued as named for cancer of the os uteri, being careful in all
operations not to carry the incisions into the rectum or bladder.

I would remark here, that some of these latter conditions, exist-
ing as causes of difficult labor, may be found present in the first
stage of labor, when they should be as promptly attended to as the
circumstances of the case will permit ; preparing the parts, if pos-
sible, so that no delay may take place during the second stage.

CHAPTER XXX.

ON DIFFICULT LABOR, FROM TUMORS, PELVIC DEFORMITIES, ETC.

The capacity of the pelvis is occasionally diminished during
labor, by the presence of Tumors in its Cavity. These tumors may

DIFFICULT LABOR — FROM TUMORS, ETC.

361

vary in their size, consistency, and pathological characters ; they
may be osseous, fibrous, adipose, steatomatous, sarcomatous or
scirrhus, and the difficulty occasioned by them, will depend upon
their size and degree of solidity. The history and surgical man-
agement of these tumors, together with other details, are not within
the province of this work, in which I will merely refer to the diag-
nostic signs, and the indications for treatment when they interfere
with the progress of labor.

A hard, bony tumor of extremely rare occurrence, termed
EXOSTOSIS, has been met with. It takes its origin from some
portion of the osseous parietes, more commonly from the sacro-
iliac symphysis, and sometimes from the first bone of the sacrum,
from the last lumbar vertebra, from the internal surface of one of
the ischia, or from some portion of the posterior face of the pubic
bones ; and may be detected by its hard, knotty and irregular feel,
its insensibility to pressure, its immobility, and its projection into
the interior of the vaginal canal, but always covered by the wall of
this canal.

TREATMENT— It is possible, that when the tumor is very
small, the labor may progress without assistance, but when it is
large, so as to materially interfere with the capacity of the pelvic
diameters, the case assumes a more serious aspect. As we can not
remove this obstruction by an operation, we must be governed by
the nature of the case. If there is a probability that the head may
pass, it will be prudent to wait until symptoms, demanding artifi-
cial delivery, present themselves, when the labor may be terminated
by the forceps, or perhaps the perforator. When the diminution
of the pelvic cavity, from this cause, is so great that the fetus can
not pass through the vagina, the only chance for the mother will
be in the performance of the Cesarean operation. Fortunately,
these instances are rare ; I have never met with one.

Other osseous tumors may occasionally render a labor difficult,
as OSTEO-SARCOMA of the -pelvis ; this is very difficult to distin-
guish from exostosis ; it presents greater inequalities, has a semi-
cartilaginous softness, a degree of depressibility, and at some parts
of its surface crepitation may be observed. From the depressibility
of this tumor, the pressure of the head may flatten it, and effect a
sufficient amplification of the parts to admit of the passage of the
fetus ; and should the natural efforts fail, or symptoms appear
24

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requiring interference, the labor may be terminated, according to
circumstances, as in the preceding difficulty.

Sometimes the pelvic cavity may be diminished by bony protu-
berances, depending upon irregular consolidation of fractures in
the part, or perforation of a carious acetabulum by the head of
the femur, etc. In these cases, whatever may be the situation of
the protuberance, the indications for treatment will be the same
as in pelvic deformities.

Vaginal cystocele, vaginal hernia, oedema of the labia majora,
cancer of the os uteri, and calculus in the bladder, have been referred
to in the preceding chapter. Beside these, there are other swellings
or tumors which may interfere with the passage of the child's head
through the pelvic cavity, and which will demand some interference
on the part of the practitioner : thus —

FIBROUS TUMORS of the CERVIX UTERI, are occasionally
met with, instances of which are recorded, where the labors were
finished without more than ordinary assistance, the mothers recov-
ering, but the children being still-born. In such cases it is better
to delay all operations, if there is the least possibility of the delivery
being effected by the natural powers; but when this is impossible,
from the excessive size of the tumor, from the want of proper
uterine contractions, or from exhaustion of the mother, the child
will have to be extracted by means of embryotomy, or if this be
impracticable, by the Cesarean operation.

A POLYPUS may arise from the body or neck of the uterus,
or it may be adherent to the walls of the vagina, and in either
case present an obstacle to the delivery. It may be known by its
firm, fleshy feel, its movability, its pear-shape, and its long, nar-
row neck : during labor it has sometimes been mistaken for the
child's head.

TREATMENT.— If the tumor be detected at an early period of
labor, it might be prevented from descending, by pressing it back
during the absence of a pain, and holding it thus until the head ha9
passed beyond it ; but this is not practicable in all instances, and
especially when the tumor is very large. In every case of this
kind, it will be proper to trust for a time to the resources of nature;
but when the parts become hot, dry, and swollen, and the uterine
efforts inefficient, interference is required, for a too protracted
delay is hazardous to both mother and child. The only operation

DIFFICULT LABOR — FROM TUMORS, ETC.

368

necessary, is the removal of the tumor by excision, and not perfo-
ration of the child's scull ; for the danger from hemorrhage after
the operation is not so great as to justify the destruction of the
child. " The polypus should be drawn down as much as possible
by a forceps proper for the purpose, a temporary ligature applied,
and the stem cut through." " It is not likely that the ovum could
be brought to maturity, if a large polypus occupied the cavity of
the uterus ; it is therefore fair to assume, that when a polypus is
found to impede parturition, it must be attached to the mouth of
the uterus, and therefore it can be the more easily traced to its
origin, so that you have every facility to assist your diagnosis." —
(Murphy.) If the presence of a polypus in the pelvic canal be
discovered during the latter period of utero-gestation, and its size
be such as to possibly render labor protracted and difficult, it
should at once be ligated and excised.

The ovary is liable to several diseases, which augment its volume
to an enormous extent. Among these, dropsy and scirrhus are the
most common ; and if, at the time of parturition, an OVARIAN"
TUMOR is present, it may become a cause of difficult labor by
impeding the birth of the child. Generally, as the gland enlarges,
it gradually rises from the pelvic into the abdominal cavity, where
from its bulk, it may interfere with the development of the uterus
and occasion a premature labor; or else, by pressing this organ to
the side opposite, it may give rise to a difficult labor, by producing
a uterine obliquity. Frequently, however, adhesive inflammation
causes the ovary to remain within the pelvic excavation; or it may
have been prevented from ascending into the abdominal cavity by
the gravid uterus having already occupied that space; in either of
which instances, if the female arrives at the full term of utero-
gestation, the labor must be exceedingly difficult, depending, how-
ever, on the size and character of the tumor.

The diagnosis of an ovarian tumor, at the period of labor, is not
always an easy matter. It will be found external to the vaginal
coats, commonly toward the posterior part of the pelvis, within the
recto-vaginal septum, will be more or less movable, elastic, and
fluctuating, or hard and apparently solid, with some degree of
sensibility. The dropsical tumor presents a round, smooth, and
polished surface, while the scirrhus one presents nodules and
irregularities. It is proper to examine in these cases both by

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AMERICAN ECLECTIC OBSTETRICS.

vagina and rectum simultaneously, for the purpose of more clearly
determining them from vaginal or uterine tumors.

TREATMENT. — In the management of these cases, much will
depend upon the size and character of the tumor, bearing in mind
that these tumors are " more likely to be moved out of the way of
the child at the time of labor, than any other, and also more apt to
give way and burst under the pressure of the head." — {Churchill.)
If the tumor be detected previous to the engagement of the head
at the superior strait, and it is movable, attempts should be made
to push it up above this strait by steady pressure, so as to place it
beyond the head. If this can not be accomplished, we must rely
upon the natural powers, until the symptoms demand our inter-
ference. If the tumor be soft, it may be flattened, or ruptured, and
thus allow the head to advance ; if it be solid, we certainly should
not interfere until we are compelled to. When the removal of the
obstacle can not be accomplished, and interference is called for, it
is recommended to puncture the tumor by means of a trocar, and
evacuate the fluid; and if the contents of the tumor be viscid, or
gelatinous, not passing readily through the canula, or if the
tumor be formed of numerous cysts, not communicating with
each other, the opening must be enlarged by making an incision
into the tumor of half an inch or an inch in extent. When the
tumor is located between the sacrum and rectum, it is recom-
mended to make the puncture through the rectum ; but in other
instances through the vagina, as there is less danger from hemor-
rhage from the vaginal bloodvessels. Should a fibrous or polypus
tumor be punctured, from an error in diagnosis, no great harm will
be done. Great care, however, must be exercised in the examina-
tion of fluctuating tumors, especially when they are toward the
pubic side of the pelvis, as the bladder may prolapse and present a
fluctuating tumor, and which must not be punctured under ordi-
nary circumstances.

If the tumor be solid, and can not be pushed up above the brim,
or if the means previously employed fail to lessen its size, the deliv-
ery should be effected by the forceps, in all cases where it is pos-
sible; but where this can not be done, the only resource left is
embryotomy, extracting the brain, and, if required, the contents of
the chest and abdomen ; unless, indeed, the physician is willing to
subject the mother to the hazard of the Cesarean operation, or the
extirpation of the diseased mass.

Dr. Merriman has recorded the history of eighteen cases of ovarian

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

365

tumors impeding labor, in which nine mothers died, three recovered
very imperfectly, and six escaped; of the children, fifteen were still-
born, and three were born alive. He states : " Twice, the labor was
effected by the pains, unassisted by the art of the accoucher ; but
one of these women lost her life, and one of the children was still-
born. Five times the perforator was used, after a longer or shorter
duration of labor : three of these women died, another recovered
very imperfectly, and one got well. Five times the labor was term-
inated by turning the child ; all the children were lost, and only one
mother recovered. Three times, the tumors having been opened,
the labor was afterward trusted to nature; two of these women
recovered, but the other remained for a long time in an ill state of
health ; two only of the children were preserved. In three cases, the
tumors having been opened, it was still found necessary to have
recourse to the perforator; one of these women died, one remained
in an ill state of health for eighteen months, and then sank under
her sufferings ; the third recovered." " Upon the whole," Dr. Mer-
riman observes, " the evidence we at present possess, is more in
favor of opening the tumors when they contain a fluid, than of any
other mode of procedure; for of the nine women who recovered
more or less perfectly, jive appear to owe their safety to this operation,
and of the children born alive, two were preserved by the same
means."

In all these cases, the time of the operation must be determined
by the constitutional symptoms, never delaying assistance after
symptoms of powerless labor have commenced. The danger, in
these tumors, arises, not so much from the obstruction to the labor,
as from the influence exerted upon the disease itself; the pressure
upon the tumor, and its consequent irritation, together with the
debility, or exhaustion of the patient, occasioned by the prolonged
and painful parturition, render her unable to sustain the effects of
the irritation and nervous shock after the conclusion of the labor.

Other tumors may be present as impediments to the progress of
labor, as FUNGUS, or CAULIFLOWER TUMORS, which,
from their spongy character and tendency to hemorrhage, may be
mistaken for a placenta prsevia ; these may spring from either lip
of the cervix, and when small, may allow the birth of the child
without any artificial aid. But when large, they may have to be
incised, or entirely removed by excision ; in either case, there will
be but a slight chance for the mother's recovery. Embryotomy and

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gastromy have both been performed in these cases, but generally,
with fatal results.

ENCYSTED TUMORS, may adhere to the cervix uteri, or to the
vaginal walls ; they are usually round, well-defined, movable, elastic,
and sometimes fluctuating, and require the same treatment as here-
tofore named for other tumors, as do also those of a Scirrhus,
or Phlegmonous character, Polypi, and various Excrescences, and
Syphilitic Vegetations which may be found on the external parts of
the generative organs.

From the great fatality which attends the presence of pelvic
tumors, as obstacles to delivery, it must be regarded as a fortunate
matter that their occurrence is not very frequent. Perhaps, less
fatality would attend these cases, when known at an early period,
and both mother and child be saved, were the induction of prema-
ture labor accomplished ; although, it is by no means improbable,
that even at the seventh month, instances may be met with which
will offer an obstacle to the operation, and with these, the produc-
tion of an early abortion affords the only chance of safety for the
mother.

As a general rule of action, in all cases of tumors at full term,
the first attempt of the practitioner should be to push the tumor up
above the superior strait, beyond the head, so as to remove its inter-
ference with the advance of the latter. And the operator will be
more likely to succeed by placing the patient on her knees, with the
pelvis elevated, and the breast on the bed, in a line with the knees;
this position deprives the patient of any tenesmic, or bearing down
power, beside causing the uterus to gravitate further from the pel-
vis, in a direction toward the epigastrium, and thus affording greater
space into which the tumor may be placed. The manipulation may
be conducted according to circumstances, with the hand in the
vagina, or one or two fingers in the rectum, or both combined.

Where the tumor can not thus be placed out of the way, it is
recommended to puncture it with a trocar, and in case this fails, to
perforate the child's head, either of which operations do not always
lessen the danger to the mother. In relation to puncturing or
incising the posterior vaginal wall, in these tumor cases, Prof. Meigs
remarks in his valuable work on Obstetrics, " I do not feel at liberty
to recommend such an operation in this volume — an operation
which could only be legitimately performed, upon due and mature

DIFFICULT LABOR — FROM PELVIC DEFORMITY. 367

consideration with the most acute and able practitioners of the
vicinity. They alone should feel themselves vested with the author-
ity to act under such terrible circumstances. I merely remark, en
passant, that an incision into the posterior wall of the vagina, should
it even have the good effect sufficiently to reduce the size of the
tumor, fearfully exposes the patient to the risk of vaginal laceration
from the subsequent distension by the descending head, and the
escape of the child into the peritoneal sac. A small aperture in the
thin posterior paries of the tube, is more likely to yield and become
a frightful laceration, than to resist the distending force of the
advancing head." These remarks, from one of the most eminent
accoucheurs of America, are entitled to the serious consideration of
every medical man. Up to this period, I have met Avith only one
instance of tumor offering an impediment to delivery ; it was a cauli-
flower excrescence of the cervix, in a female with her fifth child,
and terminated fatally.

DEFORMITIES OF THE PELVIS, are another cause of pro-
tracted and difficult labors, not unfrequently rendering the descent
of the child impracticable, and are much more common to the
women of Europe than to those of America. In Part I, I have
referred to the character of these malformations, and the method of
determining them ; it now remains to speak of the management of
labor when they are present.

The ABNORMALLY LARGE PELVIS, can scarcely be con-
sidered a deformity; but as the head of the child may meet with
but little resistance in its passage through the canals, the various
motions of flexion, rotation, etc., may not take place at all, or else be
very imperfectly effected, and thus modify the labor. The conse-
quences which may result in these kind of labors from deficient
resistance, have alread}^ been named in Part I. Where the labor
proceeds rapidly, the child may unexpectedly be expelled and fall
upon the floor, even before the practitioner has deemed it advisable
to make the usual preliminary preparations. In these cases, the
best method of management, when called in time, is, to prevent the
head from being too hastily expelled, by pressure upon it during a
pain, giving firm support to the perineum until it is sufficiently
yielding to allow the head to pass without causing a laceration, and
to guard against hemorrhage by pressure over the uterine globe.

368

AMERICAN ECLECTIC OBSTETRICS.

After delivery, the patient should be kept in the horizontal posture,
for a longer time than is usual.

The DWARFISH PELVIS, will offer an impediment to labor,
according to the degree of contraction present ; the labor may be
accomplished by the natural powers, but it will be tedious, difficult,
and attended with much suffering, and perhaps, from the long-con-
tinued compression of the head, result in the death of the child ;
or, it may be impossible for the child to be born without assistance.
And, indeed, the same observations will apply to the Unequally
Contracted Pelvis, and the Obliquely Distorted Pelvis.

The character of the labor, in these instances, will depend entirely
upon the amount of deformity, which may be arranged as follows :
1st. Where the diminution of the pelvic diameters is not so great
but that the child may be born, after a long time, by the natural
powers, aided, in most cases, by the forceps, for the application of
which there will be found sufficient space. 2d. Where the diminu-
tion of the pelvic diameters renders it impossible for the head to
advance, and the forceps can not be applied for want of space, and,
consequently, the only resource is the perforator. 3d. Where the
pelvic canal is so reduced in size, that even a mutilated child could
not be extracted.

The difficulty of the labor will not depend so much upon the pos-
itive size of the pelvic diameters themselves, as upon their adapta-
tion, relatively, to the diameters of the fetal head ; for, though the
pelvis may be considerably contracted, yet, if the child's head be
small, the labor may progress with comparatively little difficulty. A
pelvis, whose small diameter is less than three inches, may generally
be considered as one through which a living child can not pass; on
this point, however, it maybe proper to state, that accoucheurs vary
in their estimate, some placing the limit at two inches, some at two
and a half, and others at three, and even three and a quarter inches.
In instances where the small diameter is less than three, but exceeds
two inches, the labor will belong to the second arrangement or class,
as given above ; in such cases the forceps could not be employed
advantageously, or if an attempt were made to use them, it would,
undoubtedly prove useless, and perhaps injurious — the perforator
and crotchet would be demanded here. Authors likewise vary in
the limit of measurement in these labors requiring the mutilating
instruments, some placing it at one and a half inches, and others at
one and three quarters, and two inches. When the small diameter

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

369

is below two inches, the labor belongs to the third arrangement,
and will, very probably, require the Cesarean operation before the
child can be removed.

When there is a deformity of the pelvis, we are informed by Dr.
Rigby, that the uterine contractions are frequently irregular during
the first stage of labor, exerting but little influence in dilating the
os uteri ; the head remains high up, does not descend against the
os uteri, and shows no disposition to enter the pelvic cavity —
being pushed forward by the promontory of the sacrum, it rests
upon the pubic symphysis, pressing forcibly against it. The mode
of determining deformity at the superior strait, has been already
explained in Part I. When the deformity is in the cavity or at
the inferior strait, it is detected with much less difficulty, as the
parts are more readily reached ; we will discover that the head
makes no advance during a pain, and if the finger be passed
around during the absence of pain, the head will be found larger
than the canal through which it has to pass.

When the labor is allowed to proceed without interference in
these extremely deformed pelves, various symptoms may present,
which are generally met with during the second stage, as : ineffi-
cient contractions, exhaustion, and febrile symptoms, inflammation
and sloughing of the soft parts, the result of long and forcible pres-
sure of the head, and which may occur at either of the straits,
or in the cavity, and may, likewise, penetrate into the bladder,
or rectum ; rupture of the uterus not unfrequently occurs in these
cases. The child may have one or more bones of the cranium
fractured, or the pressure may cause inflammation or sloughing of
the scalp, or its death may be occasioned by strong and continued
compression of the head.

TREATMENT. — This will depend much upon the class to.
which the deformity belongs; if it be of the first class, a fair trial
should be given to the natural powers, and if they be found insuf-
ficient to effect the child's expulsion, or if symptoms of exhaustion
appear, assistance should be given with the forceps, provided there
be space enough for their application. If the case belongs to the
second or third class, I deem it advisable to operate at as early
a period as possible, before the system of the patient has become
exhausted from the long-continued exertion and sufferings of the
labor, thereby materially increasing the chances of a favorable
result. In instances where the perforator is indicated, the child
is generally dead from the pressure, before the symptoms have

370 AMERICAN ECLECTIC OBSTETRICS.

arrived at a point demanding the operation. Jn all cases where
deformity of the pelvis is suspected during labor, the practitioner
should at once proceed by a careful examination to determine the
character and location of the distortion, and the method of man-
agement should be decided upon only after a consultation with
experienced accoucheurs.

The following extract from Dr. R. Lee's Lectures on Midwifery,
relative to the treatment of pelvic deformities, will, no doubt,
prove acceptable to the reader; he observes : "In cases of slighter
distortion of the pelvis, it is impossible to predict at the commence-
ment of labor whether the head will pass or not, and while it con-
tinues to advance and no unfavorable symptoms are present, you
ought not to interfere — wait patiently and see what nature can do.
If the head descends so low into the cavity of the pelvis that an
ear can be felt, and the os uteri is fully dilated, and there is room
to pass up the blades of the forceps without the employment of
much force, it is always proper, when delivery becomes necessary,
-to attempt to extract the head with the forceps. It is necessary,
however, to remember that sloughing is apt to follow the use of
the forceps where the soft parts have been long pressed upon
by the head, and that perforation of the head is a much safer oper-
ation for the mother, when the distortion is considerable.

" The employment of the long forceps, in cases of distorted pel-
vis, has been recommended by Baudelocque, Boivin, Lachapelle,
Capuron, Maygrier, Velpeau, and Flammant, whose works con-
tain ample instructions for its use, before the head of the child has
entered the brim of the pelvis ; and the last of these writers has
expressed his belief that the instrument is more frequently required
while the head of the child remains above the superior aperture
of the pelvis, than after it has descended into the cavity.

"In this country there are no practitioners of judgment and
experience, who have frequent recourse to the forceps, or who
employ it before the orifice of the uterus is fully dilated, and the
head of the child has descended so low into the pelvis that an ear
can be felt, and the relative position of the head to the pelvis
accurately ascertained. The instrument is very seldom used in
England where the pelvis is much distorted, or where the soft
parts are in a rigid and swollen state; but it is had recourse to,
where delivery becomes necessary in consequence of exhaustion,
hemorrhage, convulsions, and other accidents which endanger the

DIFFICULT LABOR — FROM PELVIC DEFORMITY. 371

life of the mother. It is used solely with the view of supplying
that power which the uterus does not possess."

Again, "Where there exists a great degree of distortion of the
hrim of the pelvis, you may be unable to determine, positively, the
distance between the base of the sacrum and symphysis pubis;
and it is not necessary, for practical purposes, to do so with math-
ematical accuracy; but when it is under two inches and a half,
you will readily discover, if you have had considerable experi-
ence, on making the ordinary examination, from the unusual man-
ner in which the sacrum projects, that it is impossible for a child
at the full period to pass through it. If labor has commenced at
the full period of pregnancy, and you discover, before it has con-
tinued many hours, that the pelvis is greatly distorted, and that the
child can not possibly pass alive, no advantage can result from
allowing the labor to endure till the patient is exhausted, and you
are satisfied that the difficulty can not be overcome by the powers of
the constitution. In such a case delay is dangerous, and there is
nothing which can save the woman's life but opening the child's
head with the perforator, and extracting it with the crotchet. But
this should never be had recourse to without a regular consultation
of experienced practitioners, and before it has been placed beyond
all doubt, by the most candid investigation, that the delivery can
be accomplished in no other manner, so as to preserve the mother's
life.

" In the greater number of cases of difficult labor from a high
degree of distortion of the pelvis, which have come under my
observation, where it has been the first child, the process has been
allowed to go on till the efforts of the patient had been nearly dis-
continued, or had ceased entirely, and the favorable period for
operating was lost. In some cases, even when the duration of the
labor, and the local and constitutional symptoms, have made it mani-
fest that such interference was justifiable and necessary, I have
unfortunately delayed too long to deliver, in consequence of employ-
ing the stethoscope, and ascertaining that the child was alive. In
cases of extreme distortion of the brim of the pelvis the proper
practice is, to perforate the head as soon as the os uteri is sufficiently
dilated to admit of the operation being done with safety, and after-
ward leaving the patient in labor till the head has partially entered
the brim, and the os uteri is considerably dilated. There can be no
doubt that, in some cases, it is right to interfere before we certainly
know that the child has been destroyed by the pressure ; but we

372

AMERICAN ECLECTIC OBSTETRICS.

have nothing here to do with the question respecting the life or
death of the child ; our conduct will be biased if we endeavor to
solve this question. We have only to determine, positively, that
delivery is absolutely necessary to save the mother's life, and that it
is impossible for the head of the child to pass, till its volume is
reduced. Pare", Guillemeau, Mauriceau, Portal, Puzos, Levret,
Smellie, and all the best accoucheurs who have since appeared in
Britain, have performed the operation of craniotomy in many cases
of distortion from rickets and malacosteon, without reference to the
condition of the fetus. * True religion and the common sense of
mankind,', observes Dr. Denham, ' appear to have nothing contra-
dictory. The doctrine they teach, of its being our duty to do all the
good in our power, and to avoid the mischief we can, is applicable
to the exigencies of every state, and we may be easily reconciled to it
on the present occasion. In some cases of difficult parturition, it is
not possible that the lives, both of the mother and child, should be
preserved. Of the lite or death of the mother, we can, under all
circumstances, be assured : of the life or death of the child, there
is often reason to doubt, when we are called upon to decide and to
act. The destruction of the mother would not, in the generality of
cases which may bring the operation of which we are speaking
under contemplation, contribute to the preservation of the child ;
but the treatment of the child as if it were already dead, with as
much certainty of success as is found in other operations, secures
the life of the parent. It then becomes our duty, and is agreeable
to our reason, to pursue that conduct which will give us the most
probable chance of doing good ; that is, of saving one life, when
two lives can not possibly be preserved.'

"'The only means of effecting delivery,' observes Dr. Collins,
'where the disproportion between the head of the child and the
pelvis is so great as to prevent us reaching the ear with the finger,
is by reducing the size of the head and using the crotchet. This is,
however, an operation that no inducement should tempt any indi-
vidual to perform, except the imperative duty of saving the life of
the mother when placed in imminent danger. I have no difficulty
in stating, that after the most anxious and minute attention to this
point, that where the patient has been properly treated from the
commencement of her labor; where strict attention has been paid
to keep her cool, her mind easy ; where stimulants of all kino's
have been prohibited, and the necessary attention paid to the state
of the bowels and bladder; that, under such management, the death

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

373

of the child takes place in laborious and difficult labor before the
symptoms become so alarming as to cause any experienced physi-
cian to lessen the head. This is a fact which I have ascertained
beyond all doubt by the stethoscope, the use of which has exhibited
to me the great errors I committed before I was acquainted with its
application to midwifery, viz. : in delaying the delivery, often, I have
no doubt, so as to render the result precarious in the extreme, and
in some cases even fatal.'

" The operation of craniotomy is now performed by all British
practitioners of reputation, whether the child be alive or dead, if
the condition of the mother is such as to render delivery absolutely
necessary, and the head of the child is beyond the reach of the
forceps, or where, from distortion of the pelvis, or rigidity of the
os uteri and vagina, it can not be extracted if its volume is not
reduced. This operation is performed from a conscientious belief
and deep conviction that if neglected to be done at a sufficiently
early period, the mother's life will be sacrificed, and the life of
the mother is considered to be much more important than that of
the child. Some continental writers affirm, but I believe unjustly,
that in England we have frequently recourse to craniotomy with-
out due consideration, and without proper regard to the life of the
child; and, whatever the state of the parent may be, they refuse
to open the head till they can obtain certain evidence, which, in
some cases, it is impossible to obtain, that it is dead. 'Nothing
could excuse the conduct of the practitioner,' says Baudelocque,
'who would perforate the head of a child without previously
knowing with certainty that it was not alive, a circumstance which
can only authorize us to employ the perforator and crotchet.' By
following this erroneous principle, the lives of both mother and
child would, I believe, in the majority of cases, be sacrificed."

The operation of turning has been recommended, in cases of
pelvic deformity, by some authors : I consider the operation a very
hazardous one, which can not be too strongly censured, even when
undertaken in the slighter degrees of distortion. It is impossible
to tell how the diameters of the head may compare with those of
the pelvis ; and, in turning1, the head may be so placed as not only
to expose the female to the pains and difficulties incident to the
operation, but to the subsequent difficulties attending the employ-
ment of the forceps, or perhaps the perforator, one of which will
most certainly be required ; beside affording not the least chance
for the safety of the child.

374

AMERICAN ECLECTIC OBSTETRICS.

After the delivery, every means should be employed to guard
against sloughing : warm water, or an infusion of St. Johns-wort,
should be injected into the vagina two or three times a day ; or an
injection of Elm bark and Arnica flowers may be used. Febrile
or inflammatory symptoms may be combated with the tincture of
Gelseminum ; or the following powder may be administered :

Compound powder of Ipecacuanha and Opium, half a drachm ;
Sulphate of Quinia, six grains. Mix together, and divide into six
powders, of which three may be given daily, at intervals of four or
five hours.

In all instances where a deformity of the pelvis is known to
exist, and especially when from careful measurement, or the results
of a previous labor, it is ascertained that a living child can not be
born at full term, the induction of premature labor should be unhes-
itatingly performed ; likewise, in cases where the life of the mother
would be endangered from the difficulty or impossibility of delivery
at this period. And in those cases where, at the seventh month,
premature labor would be hazardous to the mother, on account of
excessive diminution of the pelvic diameters, or distortions, I
should not hesitate a moment in adopting measures to produce
abortion.*

* The following excellent observations are extracted from "Murphy's Lectures on
Natural and Difficult Parturition," London edition, 1845, and are well worthy the
attention of the student and practitioner. I have purposely omitted his Notes.

"It is hardly necessary to state to you that there is every variety, in the degree of
disproportion between the head and the pelvis. In some instances it is so slight that
the child may be safely delivered without, any assistance ; only it will occupy a longer
time in passing through the pelvis. In others, the amount of difficulty may be so
much increased as to render it doubtful whether the head can pass without assistance ;
and it is in these cases that the rules which are given for your guidance are the most
contradictory. Again: you may have a still greater disproportion, in which there is
no doubt about the improbability that the head can be expelled by the natural efforts
of the uterus, although there is very great doubt, and no little dispute, as to the means
by which the ljead must be extracted. Lastly: you have occasional instances in which
the narrowness of the pelvis is such, or the magnitude of its distortion is so great,
that the safe delivery of the child is hopeless ; the head must be lessened ; it must be
destroyed before it can be brought into the world. In extreme cases of this kind,
even this can not be done; but recourse must be had to the difficult and dangerous
operation of removing the child from the uterus by laying it open, in order to save the
mother from he dreadful alternative of dying undelivered.

"In those cases of slight deviation from the standard pelvis, where there is every
evidence of space sufficient for the head ultimately to pass through the pelvis, if
nature be allowed time for the purpose, you would not, of course, interfere with her;
although I believe instances might be quoted where very adroit operators have, even in
such cases, relieved the tedium of a long attendance by the ready application of the

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

375

One of my former colleagues has given to me the foMowing
account of two instances of injury to the coccyx, occasioning
deformity at the inferior strait, and his mode of management;

forceps. It is sufficient, to say, that the united testimony of the profession, given in
every standard work of midwifery, is opposed to such a practice; and if any accident
should arise from this mischievous meddling, the operator is fully responsible for all
the consequences that follow from it. But in those more doubtful cases, in which
there seems hardly sufficient space for the head to pass safely through the pelvis, the
practice is not so clear, nor is the evidence of the profession so unanimous on the
subject. When, in such instances, the head is actually arrested, and so remains for
some hours in the same position — a sufficient length of time to satisfy you that the
uterus can not advance it — if the ear can be felt, or the finger be passed easily between
the head and the pubis, you may use the forceps to deliver the child, and I think the
weight of authority will support your practice. But when the head is not so arrested,
but, at the same time, advances so extremely slowly that it seems to be arrested, you
have here the discordance of authorities at once confounding you. Burns devotes the
greater part of a chapter to prove the impropriety of delay under such circumstances
and advocates the application of the forceps in cases of arrest, or rather of slow pro-
gress of the head, because 'in such cases then we may experience much evil from
trusting too long to nature, but add little to the sufferings of the patient, and nothing
to her hazard, by instrumental aid.' He applies the same principle to cases of impac-
tion, which we shall presently consider. The evil he dreads is uterine exhaustion, if
this second stage be much prolonged. In this view he has the support of the late
Professor Hamilton, who equally dreaded delay. Dr. Campbell also gives a similar
opinion, but more guardedly expressed. 'It may, however, be repeated, that while the
delivery is advancing, and the patient continues free from unfavorable symptoms, the
use of the forceps is to be abstained from altogether. But whenever the progress is slow
and imperceptible, and the subordinate means already recommended have failed to
accelerate the transit of the fetus, the case should be watched, and this instrument
applied with very little delay after the passages are prepared,' Other names might be
added to this list of advocates for interference in the case supposed. But let us turn
to the other side, and you will find the eminent names of William Hunter, Osborne
and Denman, opposed to this practice. Dr. Osborne would wait until exhaustion had
actually taken place — a maxim for which he has been very severely, and I admit, very
justly criticised. Dr. Denman's fifth aphorism states, 'It is meant, when the forceps
are used, to supply with them the inefficiency or want of labor-pains; but so long as
pains continue, we have reason to hope they will produce their effect, and shall be justified
in waiting.' When the pains cause the head to advance, although very slowly, they ,are
producing their effect; and the case therefore comes within the limits of the aphorism.
Dr. Collins observes, 'Let it be carefully recollected at the same time, that so long as
the head advances ever so siowly, the patient's pulse continues good, the abdomen
free from pain or pressure, and no obstruction to the removal of urine, interference
should not be attempted, unless the child be dead: Dr. F. Ramsbotham's third rule on
this point is, 'If the head advances at all, and be not impacted, provided the strength
and spirits are good, there is seldom need to interfere.' Dr. R. Lee's name might also,
I think, be added, as being favorable to this rule of practice.

"I shall not, gentlemen, so far trespass on your patience as to ask you to unravel
with me this tangled web of contradictory experience. It is sufficient if I convince
you of the difficulty of the subject, and if it induce you to give a patient attention to

376

AMERICAN ECLECTIC OBSTETRICS.

"Mrs. 'S., about to be confined with her first child, informed me,
that, while walking over an icy, but rough piece of road, some
years previously, she fell suddenly in a sitting posture, and either

the only mode that I can adopt to draw a legitimate conclusion — that is, to derive it
as nearly as possible from facts, without reference to opinions. I think this may be
done. Bearing in mind that the great and leading principle to be observed in these
difficult cases is, to preserve both mother and child, if possible, from injury, I think
it is in our power to compare the results of cases where the forceps has been applied
with those where it has been withheld, and thus determine the practice which presents
the greatest success. We shall first direct your attention to the following tables of
operative midwifery, derived from reports given by British and foreign practitioners;
you will find in them the total number of cases given by each, the number of forceps
operations, and the results to mother and child when they are given.

COMPARATIVE VIEW OF FORCEPS OPERATIONS AND PERFORATIONS.

BRITISH REPORTS.

Pate.

Place.

Name.

Total
Cases.

Forceps.

Deaths.

Children. . Hotheri.

Perfo-
rati'os

Is

6
16
15

1

2

Total
Opera-
tions.

1781

1828 to 1843
1787 to 1793
1826 to 1833
1835 to 1837
1835 to 1840
1832 to 1835

London....

Do. ...

Do. ...
Dublin. ...

Do. ...

Do. ...

Do. ...

Do. ...

London....

Dr. R. Bland

Dr. F. Ramsboth.
Dr. J. Clarke
Dr. Collins

Dr. Churchill
Dr. R. Lee

1,897
2,947
35,745
10,387
16,414
1,182
1,640
5,699

4 /

21
49
14
24

9

3
14

6
11

8
4
1

5

3
2
4

1

8

9
38
49
79

3
12
29

12

30
87
63
103
12
15
43

75,911

138
55

35
38

10

9

227
127

44

23

365
182

FOREIGN REPORTS.

FRENCH.

1797 to 1811
1812 to 1820

Paris .
Do.

Boivin

La Chapelle.

20,357

96

23

16

112

22,243

77

18

12

89

42,600

173

41

28

201

1821 to 1825
1801 to 1821
1797 to 1827
1811 to 1827
1825 to 1827
1814 to 1827
1817 to 1828
1823 to 1827

Wurtemb'g
Vienna ....

Ghent

Prague

Bonn

Dresden....

Berlin

Do

Heidelberg

Riecke

Boer

Jansen

Moschner .

Kilian

Carus

E. Siebold.

Kluge

Naegele

221,923

2,740

636

127

98

35

2,838

26,965

100

43

143

13,365

341

5

346

12,329

120

4

1

124

9,392

120

4

124

2,549

184

9

193

2,093

300

1

301

1,111

68

14

8

3

76

1,711

55

5

60

291,438

4,028

650

127

177

39

4,205

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

377

fractured or dislocated the os coccyx, or fractured the lower part
of the sacrum, probably the latter, as the bone projected so far
toward the front as to cause the feces to be expelled in a forward

"You will perceive that in these tables the number of forceps operations in British
practice is 138; in thirty -five of which the child was still-born, being in the propor-
tion of one in every fourth case. In order to prevent error in this proportion, we have
separated Dr. Lee's forceps cases; the total number of which given by him is fifty-five;
the mortality of children, thirty-eight; which would be quite out of proportion (being
more than one-half ) if these cases were not carefully examined. I have endeavored
to do so, and to make the necessary corrections. In nineteen of these fifty-five cases,
the forceps failed: they therefore became cases of perforation; of the remaining
thirty-six cases, one-half the children, eighteen, were lost, but twelve of these eighteen
were destroyed by other causes than the forceps. Deducting, therefore, all such cases
from the whole number, the remainder will be twenty-four forceps cases, in which
eighteen children were saved and six lost, being in the same proportion, one in four.

"In the French reports, forty-one children were lost in 173 forceps operations, being
one in four, nearly.

" In the German reports of Riecke and Kluge, which state the mortality of the chil-
dren, the number of their forceps operations united, is 2,808; the deaths of children,
650; being also one in four, nearly. Thus, then, we may conclude, that one-fourth of
the children delivered by the forceps are lost. AVhat is the result when these pro-
tracted cases are left to themselves ? Is the mortality increased ? I do not think
such will be found to be the case. In order to determine this question, I must refer
you to Dr. Collins's valuable report — the only report which, from its extreme accuracy
and minuteness, affords the elements upon which to form a calculation. Dr. Collins
has given tables to show the duration of labor in all the cases he reports ; he has
also given separate tables to show the duration of labor in forceps cases, and in those
which were preternatural. We may also assume, that perforation being only had
recourse to 'when, after the most patient trial, the impracticability of labor being
terminated in safety by any other means was clearly proved,' that all these cases
exceeded twenty-four hours. From these data, then, we shall endeavor to draw a fair
conclusion. .

Cases of Labor protracted to 24 hours and upivard from Dr. Collins' report.

TOTAL CASES, 430.

STILL-BORN CHILDREN, 150.

MOTHERS DEAD, 40.

by perforating ... 79
preternaturally.. 15

430

Still-born 4

Do 79

Do 6

Do 61

150

Do 15

Do 0

Do 25

40

1

" From this table you perceive, that of 430 cases in which labor lasted twenty-four
hours or exceeded it, 324 of them were natural cases, delivered without assistance, and
that of these 324 the children were lost in sixty-one instances, which would be about
one in five cases. The result of my own inquiries on this subject is nearly similar
and has been obtained from the same source, the Dublin Lying-in Hospital.

25

378

AMERICAN ECLECTIC OBSTETRICS.

direction, and near the external orifice of the vagina. She men-
tioned this condition of the parts as a probable source of difficulty
in the labor.

Report of 218 cases of Labor protracted to or beyond 24 hours.

Delivered.

Cases.

Boys.

Girls.

Mothers
Dead.

Causes of Mothers' death.

Living

Dead

Put id

Living

Dead

Putrid

14

4

1

5

4

4

f 1 Puerperal fever.
\ 1 Rupture of uterus.
/ 1 Puerperal fever.
\ 1 Rupture of uterus.

29

20

1

7

1

6

175

76

19

5

52

22

1

8

3 Puerperal fever.

218

80

40

6

57

33

2

18

"In 5,699 cases, 218 were protracted to this degree; and of these, 175 were delivered
naturally, and forty-one children not putrid were still-born, being one in four, nearly.
Thus, then, you perceive that, taking the widest, and we would say, the fairest view of
this question, the proportion of still-born children in these difficult and protracted cases
is nearly the same, whether the forceps be employed or otherwise; that the difference,
if any exist, is in favor of Dr. Collins's practice of leaving these cases to na ture. But
this is only one view of the question.

" It may be said, and has been said, in the energetic language of Dr. Burns, that the
mother must be considered. 'From the strength of the recommendations of the partisans
of nature, we should suppose that whenever the child could actually be born without
aid, no hazard occurred ; and, on the other hand, that instruments must of necessity
prove not only very painful in their application, but dangerous in their effects. Now
the first supposition is notoriously wrong, for innumerable instances are met with, where
the mother does bear her child without artificial aid, and much doubtless, to the tempo-
rary exultation of the practitioner, but, nevertheless, death takes place, or at the best, a
tedious recovery is the consequence.' Is such the case? It is totally opposed to my
personal experience ; on the contrary, I have been surprised at the rapid recovery of
patients who have suffered this protraction, when I had erroneously anticipated, from
that very circumstance, all the unpleasant consequences here detailed. But I would
again ask you to put aside, for the present, individual experience, and examine the
facts. In doing so, our data are more limited than those which assisted us in the former
question, because, in the French reports, there is a most ominous silence regarding the
mortality of the mothers — they say nothing about it. In the German reports, we are
limited to that of Dr. Riecke, who gives 127 deaths in 2,740 cases, being one in twenty-
one, nearly. But take Dr. Churchill's more extensive researches on this question, from
whose valuable work on operative midwifery these tables of foreign practice are partly
formed. He states, that 'among the French and Germans, in 479 cases, thirty-five
mothers were lost, or about one in thirteen.' Dr. Churchill gives the proportionate
mortality in British practice as one in twenty-one; but you perceive that, in the com-
parative view we have placed before you, there were ten deaths in 138 cases which is
about one in thirteen. Compare this with the results where the cases have been left to
the natural efforts. In Dr. Collins's report there were twenty-five deaths in 324 cases,
or one in thirteen, precisely the same as where the forceps had been used. Among

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

379

" On making an examination, I found that the bone pressed
forward in a direction nearly or quite horizontal when the patient
was standing erect, and was at least two inches long from its angle

those cases which I have observed, there were eight deaths in 175 cases, or one in
twenty-two — a proportion in which I can place the more confidence, because it ia
derived from personal observation.

With regard, then, to the second question, the mortality of the mother, take the
estimate in any way you please, and you must arrive at the same conclusion — viz.:
that the mortality is certainly not increased when these cases are not interfered
with, and all the dreaded consequences which Dr. Burns anticipates from such
practice have no foundation in fact. But we might even go farther; we might say,
that so far from such evils following our Fabian practice, the evidence seems to point
the other way, and to prove that the actual mortality is diminished. The twenty-five
deaths reported by Dr. Collins include cases of puerperal fever, and other causes of
death which might be called accidental, because he gives, under a distinct head, the
number of deaths, the 'effects of tedious and difficult labors.' There are just eleven
cases, or one in thirty cases, nearly. The eight deaths which took place under my
own observation, include three deaths from puerperal fever, leaving only five deaths
from the severity and protraction of labor, which would be in the proportion of one
to thirty-seven cases. Caution, however, is necessary, when we would derive a just
conclusion from statistics. It is therefore possible, that if the reports of these forceps
operations were more fully given, so as to separate the deaths from accidental causes
from those resulting from the operation, the proportion of mortality would be dimin-
ished in the same ratio. We do not wish you to assume more than what we think has
been proved — viz.: that the mortality of mothers is not increased by leaving these
cases to nature. The safety of the mother or child can not, therefore, be advanced as
a reason for instrumental delivery, when the head is making a very slow, but a certain
progress.

" One argument, however, has been much used by the advocates for interference,
which is very clearly expressed by Dr. Burns: 'Granting (he observes) the recovery
to be excellent, is it no consideration that the patient has been subject to twelve, per-
haps twenty-four, hours of suffering of body and anxiety of mind, which might have
been spared ?' You must perceive that if this argument be worth anything, it will
admit of a much more extended application than Dr. Burns would give to it. It might
be employed to justify the use of the forceps in every case where the head was within
reach, and labor at all severe. Because, why should your patient be exposed to any
bodily suffering or anxiety of mind, if it were in your power to relieve her from her
miseries ? On this principle, the forceps might be used (as indeed they have been) in
every tenth case, and the practitioner relieved from the most anxious portion of his
duties. But the design of nature will not thus be thwarted; and we might reply to
such an argument in the language of Noegele: 'If we admit that proportionate difficul-
ties, according to the constitution of each individual, and an effort of strength
(requisite in childbirth), are inseparable from the nature of this process, we must con-
clude that an abbreviation of this process, though performed by an able hand, before t he sal-
utary change, on which the preservation of health depends, has taken place in the
organization of the mother, that a premature and sudden removal of these difficulties
can not be a matter of indifference; that such a violent interference with the functions
of nature must incur the risk of destroying the health, though this should not ensue
for some time after.' A more immediate injury, however, sometimes follows the appli-

380

AMERICAN ECLECTIC OBSTETRICS.

of juncture with the sacrum, at which point it was firmly anchy-
losed. Judging it impossible for a full grown fetus to pass through
the narrowed passage, I explained the nature of the difficulty, and

cation of the forceps in the case we are supposing,'as well as in cases of impaction.
The pressure of the instrument may cause slough of the neck of the bladder or the
urethra, and thus establish a fistulous opening into the vagina; and the incontinence
of urine that follows renders the patient's life miserable afterward. It is difficult, in
all instances, to trace this accident to the use of the forceps. When a forceps opera-
tion is described to us, we are seldom told that any mischief is the consequence. The
splendor of success is very dazzling, and while we admire the operation, we are too
often left in the dark as to the effects.- Nevertheless, I have been able to trace this
accident clearly to the use of the forceps in several instances. The usual account
given by the patient is, 'that she had been delivered by instruments, and the child's
life saved.' Dr. R. Lee, in his 'Clinical Reports,' gives a candid and clear statement
of the results in the forceps cases he details: 'Four died from the rash and inconsider-
ate use of the forceps; seven had the perineum more or less injured; one had the
recto-vaginal septum torn ; five were left with cicatrices of the vagina, after sloughing;
and one with incurable vesico-vaginal fistula.' Dr. Collins records only one case of
vesico-vaginal fistula in the whole of his report of 16,654 cases — that was a case of per-
foration— consequently this accident never was found among those cases which were
delivered naturally. The only case of fistula which occurred in the 5,699 cases to
which I have so often referred, was one in which I employed the forceps to deliver
a child that presented the forehead. The principal cause of difficulty in Dr. Collins'
cases, was the large head of the male child forcing its way through a very osseous pel-
vis; the pressure on the soft parts must be very great, and if fistula could be produced
by great protraction of labor in cases that ultimately were delivered without assist-
ance, it must have been an accident of frequent occurrence in these cases, when the
soft parts were so much compressed ; but such did not happen, and therefore they
afford a very favorable contrast to the cases delivered by the forceps in nearly similar
circumstances. The intelligent practitioner would therefore hesitate to expose his
patient to the risk of vesico-vaginal fistula, for the mere gratification' of shortening the
severities of labor.

" We have been reluctantly compelled to dwell longer upon the management of this
degree of disproportion than we desired. The difficulty of the question it involves, and
the contradictions among the most experienced writers, must be our apology. In the
case that we are considering, that in which the second stage of labor is protracted, and
the head of the child advancing very slowly, we have shown you that there is no
increased danger to the mother or child by leaving the case to nature in place of
delivering by the forceps ; that if there be any difference in the ratios of mortality, it
is in favor of non-interference, and rather against the forceps. We have pointed out,
as far as imperfectly detailed facts would enable us, that the post-partum accidents of
labor follow operations with the forceps more frequently than cases which are left
to themselves, and, consequently, the conclusion at which we must arrive, is hostile to
the use of that instrument, under the circumstances stated. But recollect, that there
is no general rule without an exception, and you will sometimes meet with cases so
feeble in their habits that they will not endure a protracted labor without great risk
of exhaustion; you may be called to patients where you dare not temporize, whom you
must deliver althongh the head is making a tardy progress. We only ask you to con-
der these as the exceptions, not often met with, but etill necessary to be studied and

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

381

the proposed mode of removing it. "With her consent, 1 passed
both my thumbs up the rectum and placed them on the internal
part of the protruding bone, while my closed hands were upoiyts

understood. It is for this reason we have brought before your notice the symptoms of
exhaustion, and those which precede it ; the same desire to direct your attention to the
study of individual cases which may be exceptions to the general principle, we would
wish to govern you, leads me to bring before you the varieties, not only in the forma-
tion, but in the resistance of the pelvis, so that you may know where an operation
might be undertaken and where it can not be attempted. If we have placed this sub-
ject before you with sufficient clearness, we shall conclude by directing your attention
to that opposition in the practice of experienced authorities which has rendered its
discussion so necessary.

Name.

Total Cases.

Forceps.

Proportion, 1 in

Clarke,

Collins,

35,745
10,387
16,414

42,600

26,965
9,392
2,549
2,693

49
14
24

173

100
120
184
300

729 £

742, nearly.
684, nearly.

246

269J
78
14
9

London.
Dublin.
Dublin. *

Paris.

Vienna.

Dresden.
Berlin.

Ramsbotham, one forceps operation in 700; Siebold. one in nine cases!

* • •*•••<

"The management of cases where the head of the child becomes impacted, has been,
I regret to say, almost as much a question for controversy as that which we have just
discussed. It is admitted that the child must be delivered by the resources of art, but
how these resources are to be applied is the matter in dispute. Some consider that
even in these cases the forceps, skillfully employed, may effect the object in view; the
woman may be thus delivered, and possibly the child preserved. Others dread such
application of the instrument, because of the injury that may be done to the passages,
and consequently they esteem the probable danger to the mother to be a risk too great
to encounter for the very slight chance of saving the child. Hence the question lies
between perforation of the head of the child and its forcible extraction by the forceps.

"It would be most desirable to determine the rule of practice in these very difficult
cases, by an application of the same principle that was proposed to you in the last lec-
ture. If we could compare such cases as have been delivered by the forceps when the
head was impacted, with those in which recourse was had to perforation, if we could
contrast the results, we might be able to arrive at a conclusion that would satisfac-
torily resolve our doubts upon the subject; but, unfortunately, that is impossible. We
have no statistical knowledge of the effect of the forceps in these special cases ; and
the mortality that is reported under the head of perforation seems to be dispropor-
tionately increased by the circumstances under which the operation has been generally
performed.

"From the earliest period, the profession have been accustomed to look upon cranio-
tomy with dread — I might almost say with horror. A natural reluctance to destroy
human life, no matter under what necessity, has been greatly increased in some coun-
tries by religious prejudices ; and the anathema of the doctors of the Sorbonne still

382

AMERICAN ECLECTIC OBSTETRICS.

external part. By making all the effort my strength and position
would allow, I succeeded in breaking the bone at its angle, and
pushed the lower portion considerably backward. .This caused

exerts an influence that paralyzes the judgment of the practitioner. Hence we read
of cases allowed to remain several days in labor, until not only the death, but the
putrefaction, of the child, give evidence that the perforator might be employed without
any stings of conscience. The result of such practice was, as might be supposed,
inflammation of the passages, advanced to such an extent that the mother was sacri-
ficed to this procrastination; and hence in the tables of mortality we find that one
mother in every Jive, and sometimes one in every four, died after the operation. We can not
therefore, determine the rule of practice by statistical returns. We must only hope to
do so by a fair examination of the question itself, by collecting the general experience
of the profession, and by submitting to you the ground upon which we have formed the
opinion which would govern us as to the course to pursue. We do not wish you to
adopt this opinion unless you are satisfied of its correctness; we but ask you to exam-
ine the subject dispassionately, and to discard from your minds the damnatory lan-
guage that too frequently is employed by some obstetric authors. When you find an
operation spoken of as 'murderous,' you are not disposed to become the murderers:
you doubt and hesitate, and perhaps ultimately commit a double homicide. An appeal
to harsh expressions is generally esteemed an evidence of weakness in argument;
therefore, when you find these hard words, you can appreciate their value, and pass
them by for more conclusive reasoning.

" In order to compare the forceps and perforator in the case supposed, you must
view the forceps as something more than a substitute for power of the uterus. In order
to extract the head, it must also lessen its dimensions; it must be employed for the
purpose of compression as well as for extraction. When we come to examine the different
instruments used, you will find, in the varieties of the forceps, that some are shaped
especially for this purpose, which is seduously avoided in the construction of others — a
sufficient proof of want of unanimity on this important subject. Let us, then, exam-
ine the forceps as an instrument for compressing the head of the child, so as to adapt
it to the diminished space in the pelvis.

"We have already evidence before us to prove that the power of the forceps for this
purpose is extremely limited. The experiments of Baudelocque are referred to in
almost every popular work on midwifery, and, notwithstanding the critical objections
raised against them, they are sufficiently important briefly to state them to you. Being
desirous to determine the extent to which the forceps could compress the head, Baude-
locque performed nine experiments on the heads of still-born children with Levret's
forceps, an instrument of the strongest kind, and especially adapted for compression.
The utmost force was exerted to reduce the head — a force so great as to bend one forceps,
although highly tempered : the head was not lessened more than two lines, unless
where the bones were unusually soft and loose, and then only to four lines. These
experiments satisfied Baudelocque that the diminution could not be, in any case, so
much as accoucheurs had stated, and that the degree of reduction should never be
measured by the distance between the handles when pressed together, nor from the
amount of force employed to approximate them.

"In these experiments more force was used than you could venture to exert if the
child were living, and yet the space gained was scarcely sufficient to admit the blades
of the instrument to be introduced within the pelvis. They seem to me, therefore, con-

DIFFICULT LABOR — FROM PELVIC DEFORMITY. 383

very severe pain for a short time, but left the parts so that delivery-
occurred without any difficulty, and she readily and permanently
recovered; about two years subsequently, she was delivered of

elusive as to the limited power of the forceps when used as a compressing instrument.
Nor can I agree in the opinion of Dr. Rigby, that ' the slow and gradual pressure of the
forceps, thus exerted [by tyirig the handles tightly together, and tightening them after
every successive effort] upon the head of a living fetus, will have a very different
result to that of the experiments of Baudelocque and others, in attempting to compress
the head of a dead fetus by the application of a sudden and powerful force.' It is
impossible to grasp the forceps for the purpose of moving the impacted head, without
applying to it a sudden and powerful force; and if this force be maintained in the
. interval of the pains by ligature, such powerful, constant, and at the same time
unequal pressure, acting on the head of the child, would appear to me much more haz-
ardous than even the compression of the contracted pelvis, which is known to be a fre-
quent cause of the child's death.

"The possibility, therefore, of reducing by the forceps the impacted head to that
degree that will enable you to draw it safely through the pelvis, seems to me extremely
doubtful. If it were the large head of the male child, advanced in its ossification, and
wedged in the deep, narrow cavity of the masculine pelvis, I would say it is impossi-
ble. The only case where it might, perhaps, be successfully at tempted, is in the diseased
pelvis, which may be capable of some degree of expansion, and where the head of the
child, being less ossified, is softer and more compressible.

"Let me now direct your attention from the child to the mother: and admitting it is
possible, and only possible, to save the former, let us inquire into the risk to which the
latter is exposed, in the attempt to accomplish this object. The very nature of the case
implies an unusual degree of pressure on the soft parts between the head and the
pelvis: congestion must be the result; and if inflammation have not already taken
place, the passages are in such a state that inflammation could be most easily excited.
The .blades of the best contrived forceps can not be applied to the head when it is tightly
impacted in the pelvis, without bruising the soft parts to a certain extent. This con-
tusion becomes a center around which inflammation takes place, may increase to any
extent, and terminate either in a local slough of the compressed part, or a general
gangrene of the vagina, if the inflammation assume an erysipelatous type. In the
former case, the separation of the slough may be the formation of vesico-vaginal fistula.
In the latter, death may be the result. You will admit that such consequences are of
too grave a nature to hazard for the slight chance of saving the child, and therefore,
when you are placed in the unpleasant alternative, either to save the child at the risk
of the mother's life, or to sacrifice the child in order to preserve her, you must adopt
the maxim which governs British midwifery, and consider the safety of the mother
to be your first object. But you will seldom be placed in such a dilemma, if you observe
closely a case of this description. If you are satisfied that the forceps can not be
safely introduced; if you think that you can not compress the head sufficiently to
extract it without exposing your patient to a tremendous hazard ; it does not follow
that you must destroy the child in order to deliver her. In the great majority of such
cases, nature provides against the difficulty of the case by doing so herself. When the
head is thus wedged, the liquor amnii discharged, and the uterus strongly contracted
about, the body of the child, it is seldom saved from the effect of this extreme pressure:
its death is the result; and if the case be left altogether to itself, the child becomes

384 AMERICAN ECLECTIC OBSTETRICS.

a second and large child, without any trouble from the coccyx, or
sacrum.

" About six years since, I was called to attend Mrs. A., who, her

putrid, the bones of the head looser and more compressible, and thus it is possible that
it might be expelled by the uterus. Formerly, it was customary to wait for 'these
signs of the death of the child' before perforating, but being those of putrescency, the
patient was exposed to all the consequences that would follow decomposition of its
tissues in the uterus, and hence the death of the mother was too often the result. But
now we have it in our power to ascertain its death by another means, which is available
long before putrescency takes place. The stethoscope has been found to be a valuable
aid to the obstetrician; it sometimes enables him to determine the existence of preg-
nancy when all other means fail; but I know of no case where it is of more important
service than in that which is before us, nor is there any in which its evidence is more
certain. Inj pregnancy, when the child is small, the liquor amnii abundant, or the
muscles of the abdomen strong, the fetal heart may not be heard; but in parturition,
when the liquor amnii is discharged, the child full grown and perhaps large, the mus-
cles of the abdomen stretched to their fullest extent, its pulsations are perfectly audi-
ble; and if once heard, there can be no change in the situation of the sound, because
the child is fixed in its position. A close attention, therefore, to the fetal pulsations is
necessary in such a case; and when they rapidly inci-ease in frequency, then intermit,
again return more feebly, and ultimately cease, you can have no doubt the death of the
child has taken place. To prove to you the value of the evidence in this way obtained,
I shall quote the very important experience of Dr. Collins as to these kinds of labors.
He says: 'I have no difficulty in stating, and that after the most anxious and minute atten-
tion to this point, that where the patient has been properly t reated from the commence-
ment of her labor, where strict attention has been paid to keep her cool and her mind
easy, where stimulants of all kinds have been prohibited, and the necessary attention
paid to the state of her bowels and bladder, that, under such management, the death of
the child takes place, in laborious and difficult labor, before the symptoms become so alarming as
to cause any experienced physician to lessen the head. This is a fact I have ascertained
beyond all doubt by the stethoscope, the use of which has exhibited to me the great
errors I committed before I was acquainted with its application to midwifery, viz.: in
delaying delivery often, I have no doubt, so as to render the result precarious in the extreme, and
in some cases even fatal.' This observation of Dr. Collins would apply to many cases of
perforation that are recorded, and which have been followed by such frightful conse-
quences that it is not surprising that they should excite the disgust o^ the profession.
They were cases where the operation was useless, because performed too late. By
means of the stethoscope it is in your power to prevent this, and to deliver the child in
sufficient time to save the mother from injury. No one is justified in destroying a living
child, unless there is clear evidence, from the symptoms, that the mother is in
danger. According to the old rule of practice, therefore, you were placed in the
dilemma, either to wait for such symptoms, or for the signs of putrefaction in the
child — alternatives equally dangerous to her; but if the death of the child can be
known the moment it takes place, and if it be true that its death precedes those dan-
gerous symptoms, it is obvious that its removal by the crotchet is no longer objectiona-
ble, and perforation is deprived of all its horrors. So far as the safety of the mother
and the preservation of the passages from injury are concerned, there is no comparison
between perforation and the foi-ceps. In this respect perforation is a far safer operation,

{

DIFFICULT LABOR — FROM PELVIC DEFORMITY.

385

husband informed me, had two children dissected within her, and
removed by pieces, in two previous labors. Neither he nor his
wife could explain why the last two children could not be as readily

if ordinary caution be exercised; the objection — the sole objection that condemns it, is
the fact that the child must be destroyed, either by the uterus, or by the instrument.
We freely admit the cogency of the argument ; but when it is weighed against the still
greater objection, that in the attempt to save the child, the soft parts of the mother
may be injured to a most dangerous extent, while the preservation of the child is
extremely doubtful; when we find, in the imperfect history of these operations, such
as they are given to us, that the child is very generally lost, or, if there be an excep-
tion in which the child is with difficulty saved, the case is recorded with that triumph-
ant acclamation that proves the success to be unexpected: when the risk to the mother
is so great, and the prospective advantage so doubtful, you will admit that the balance
is in favor of an operation by which, if properly performed, and with sufficient prompt-
itude, the safety of the mother is at least secured.

" We are not generally favored with a faithful history of cases that illustrate the
mischievous effects produced by the forceps. On the contrary, while the post-partum
accidents of a skillful operation are deeply concealed in the shadows of the back-ground
of the picture, the surprising, the almost miraculous, power of the instrument is put
prominently forward, with all the vividness of a most glowing and high-colored
description. Thus the truth is concealed from you, and so would remain, until exposed
by your own dear-bought experience, except that you find scattered through the works
of men whose skill is acknowledged, ominous hints and anxious warnings against the
improper application of these instruments. Many evidences might be quoted to this
effect : we shall direct your attention to a few of them. Your late respected professor,
Dr. Davis, paid a great deal of attention to the subject of instrumental labors, and
was disposed to advocate a much bolder use of the forceps than what I should recom-
mend; nevertheless, he candidly admits, that 'of all the instruments used in the prac-
tice of midwifery, those of the present class [the forceps] are unquestionably the most
dangerous to the mother, inasmuch as in all cases where the forceps are used, the maternal
tissues are more or less liable to contusion. All the fangs and framework of the
instrument are made of tempered steel, and let them be ever so well covered and
defended, they will still retain a great degree of hardness, calculated to bruise and
fret the soft and living texture which might be interposed between their covered sur-
faces and the solid walls of the pelvis.'

"The same impression of mischief leads Dr. F. Ramsbotham to warn the practitioner
that 'cautiously and tenderly must this iron instrument be used! We must recollect
that no sensation can be imparted to the operator's hand of any injury that may be
done to the woman; and we must remember that one injudicious thrust, one forcible
attempt at introduction, one violent effort at extraction, may bruise, may lacerate,
may destroy!' Dr. Blundell addresses his pupils thus — 'When, however, you lay your
hand upon the tractor, or forceps, remember, that the accoucheur who is meddlesome
may be guilty of occasioning laceration of the perineum, rupture of the vagina, com-
pression and death of the child, inflammation of the abdomen of the mother, and many
other fatal consequences, which I myself have had occasion to see — a list of offenses surely
sufficient to alarm the prudent.'

"But let us come to more direct evidence. Riecke, in his report of the practice of
the kingdom of Wurtemberg, gives the result of a very large number of cases, and

386

AMERICAN ECLECTIC OBSTETRICS.

delivered, as two previous ones to which she had given birth. On
examination, I found the child's occiput under the pubic arch,
where, I was informed, it had been detained for several hours.
It was likewise mentioned to me, that in the labor preceding this,
the child's head remained impacted in about the same place for
several days before it was removed by the perforator. From near
the crown of the head, I could trace a depression of the skull,
about as broad and as deep as the diameter of my thumb, which
could be followed to the eyebrows. I then ascertained that the
coccyx had been dislocated, and that it was turned in at right
angles with the remaining part of the bone, to the extent of nearly
an inch. It was this, therefore, which had obstructed the delivery
of the child, and had caused the depression upon its skull. At the

among them, those in which the attempt was made unsuccessfully to remove the
impacted head by the forceps. He observes — 'Almost always, perforation was pre-
ceded by attempts to apply the forceps, and to the great injury of the mothers, because
perforations, not preceded by such attempts, presented much more favorable results.
The trials at extraction with the forceps — which many accoucheurs con-
tinue, to the extinction of the infant's life (although foreseeing the necessity for per-
foration)— exhaust the mother to that degree, that she necessarily sinks under the
effects of these violent efforts.' In allusion to similar inquiries, Dr. Collins remarks —
'It is from being thoroughly convinced of these facts by long and extensive observa-
tion, that I consider the forceps quite inapplicable when the head becomes fixed in the
pelvis, and the ear can not be reached by the finger except by violence, in consequence
of disproportion existing between the head and the pelvis. . . . The results I have
witnessed from such practice [delivery by forceps] were most distressing: in some the
neck of the bladder or urethra either lacerated or the injury by pressure from the for-
ceps so great as to produce sloughing and consequent incontinence of urine; in others,
the recto-vaginal septum destroyed, either of which renders the sufferer miserable for
life; and in two cases, where the mouth of the womb was imperfectly dilated, so much
injury inflicted on this part as to terminate in death.' Dr. R. Lee, in his Lectures,
quotes the paragraph at full length from which these passages are extracted, and adds:
'The accuracy of these remarks is fully confirmed by all the forceps cases which have
come under my observation, which exceed sixty in number.' It would occupy too
much time to accumulate further testimony to the same effect. I trust sufficient has
been placed before you to authorize the conclusions at which I have arrived, and which
are now submitted to you — viz. : that when the head is impacted in the pelvic cavity,
it can not be delivered by the forceps without such injury to the passages as might
endanger the mother's life ; that the probability of preserving the child's life is not
sufficiently certain to justify an attempt which might be so hazardous; that in a great
majority of these cases the death of the child takes place naturally, and it may be
removed before symptoms dangerous to the mother present themselves; and lastly,
that if it should happen that the reverse occurs, and danger to the mother — whether
from exhaustion or extending inflammation — is indicated before the death of the child,
that then perforation is called for, rather than render the risk to the mother a cer-
tainty, by the dangers that result from a forcible extraction by the forceps."

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 387

time of the examination the head was immovably impacted, and
as the forceps seemed only to flatten the head laterally, and
increase its antero-posterior diameter, I was obliged to content
myself in simply doing what I could with my hands, trying to les-
sen the obstruction by pressing the head against the pubis.

"After more than an hour of uninterrupted effort, both on the
part of the patient and myself, the head finally passed, but badly
bruised. As soon as the chin escaped, I brought my thumbs to
bear upon the protruding bone, and broke it, so that it did not
interfere with the rest of the delivery. I then learned, that after
the birth of the last living child, the mother, while carrying two
buckets of water, one in each hand, slipped and fell in a sitting
posture upon a small stone lying in her path, and so injured her
spine as to cause a lameness for several weeks. I have since
attended the same female, at the birth of two children, in which
she had no difficulty, the os coccyx appearing to be in its normal
position.

CHAPTER XXXI.

ON DIFFICULT LABOR, FROM MAL-POSITION OF THE HEAD, PRESENTATION OF THE
FACE, EAR, ETC.

Difficult Labor may arise from TOO EARLY A DEPAR-
TURE OF THE CHIN" EROM THE BREAST — an Abnormal,
or Premature Extension of the Head — giving rise to the Brow Pre-
sentations of some authors. The nearer to the center of the pelvic
cavity we find the posterior fontanelle, the greater will be the
flexion of the head, and the more readily will it advance ; and the
nearer to the walls of the pelvic cavity we find this fontanelle, the
greater will be the abnormal extension, or the departure of the
chin from the breast, and the more slowly will labor progress ; it
is an excess of this departure which gives rise to face presentations.

In all normal vertex presentations the posterior fontanelle should
be down toward the axis of the pelvic cavity, nearly in approxi-
mation with it ; but in proportion as it recedes from this point,
and approximates toward the side of the pelvis, will the anterior
fontanelle be brought toward the center of the excavation. And
at an early stage of the labor, this abnormal position may be
known by finding this latter fontanelle near the center of the

388

AMERICAN ECLECTIC OBSTETRICS.

pelvis; but, if the head should have advanced as far as the inferior
strait, one of the parietal protuberances will be at the pubic arch,
while the anterior fontanelle will be found looking toward the
inner perineal surface.

TREATMENT. — In a difficulty of this kind, the labor will
speedily be finished, after having restored the flexion. To accom-
plish this, two modes are advised ; the first is to be performed
when the head has not entirely passed the superior strait, the os
uteri being well dilated, the membranes ruptured, and the pains
sufficiently energetic. And, when possible, it is always better to
effect the adjustment at this period, than when the head has com-
pletely passed through the superior strait. Should any obliquity
of the uterus exist, it must first be removed, according to the pre-
ceding directions, page 340 ; then introduce two or three fingers
into the vagina, and during the absence of pain, slightly elevate
the forehead and hold it thus, supported by the fingers during
one or more pains, until the vertex is found to descend, and the
forehead to apparently ascend, when the fingers may be withdrawn,
and the case left to the natural powers. The object of the opera-
tion is not to push the anterior fontanelle above the superior strait,
which will be found a difficult task, but to make counter-pressure
during a pain, to prevent it from descending any further, thus
allowing the vertex, or occiput to descend with the expulsive efforts
of the uterus, and which will restore the normal flexion of the
head. It may sometimes require the introduction of the whole
hand, to effect this change. In performing this operation, the
practitioner should be careful not to make any pressure upon the
anterior fontanelle itself, but only in its neigborhood.

The second mode of operating is to be pursued when the head
is completely in the excavation. The fingers, or half of the hand,
if necessary, must be introduced into the vagina, and perhaps,
also, within the cervix, so as to grasp the posterior-superior por-
tion of the head, and during the absence of a pain, the head should
be directed, or pressed in such a manner as to bring its anterior por-
tion against that part of the pelvic wall facing it, while at the
same time the fingers should obtain a purchase on the edge of the
parietal bones, formed by the gliding of the occipital bone under
them, and carefully pull the vertex down toward the center of the
pelvis ; this accomplished, the vertex should be retained thus, until a
subsequent pain renders the change permanent. Thus, if the vertex
be toward the left acetabulum, the head will be pressed toward the

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 389

right sacro-iliac symphysis, while, at the same time, the vertex is
pulled downward. The hand to he introduced in this operation must
be that, the palm of which is directed toward, or may be applied
upon, the vertex. In cases of this kind but little could be accom-
plished by making pressure upward, with the fingers upon the fore-
head, besides which, the upper edge of the os frontis being imper-
fectly ossified, the force required to elevate it might indent the
yielding bone, and produce some injury to the brain ; hence it is
better to apply the power to the more perfectly ossified posterior
edges of the parietal bones. Sometimes, but very rarely, a vectis
will be required to effect the proper adjustment of the head when
in the pelvic cavity.

It was remarked in the Chapter on the Mechanism of Labor,
that in occipito-posterior positions of the head, the movement of
rotation usualty changed them so that toward the latter period of
labor, the occiput became placed under the pubic arch, the same
as if the positions had been originally occipito-anterior. Sometimes,
however, this change is not effected, and the head presents at
the inferior strait, with the occiput to the sacrum, and the FORE-
HEAD TOWARD THE PUBIC ARCH. If the diameters of the
pelvis and fetal head be normal, and the contractions of the uterus
efficient, the delivery mayj be accomplished without any interfe-
rence ; the head may be expelled presenting its occipito-frontal diam-
eter to the antero-posterior diameter of the inferior strait, or the
forehead may remain at the pubic arch until the posterior part of
the head has passed over the perineum. This position of the head,
notwithstanding it may not interfere with a safe delivery, may be
considered a mal-position. In 29,684 cases recorded by various
authors, theforehead was under the pubic arch in 87, or about 1
in 342J ; and of 22 children born in this position, where the results
were noted, 9 were lost.

As remarked above, the delivery may be safely accomplished by
the natural powers ; and where the head isJarge, or the pelvis
narrow, or where both these conditions occur at the same time, the
labor will be necessarily protracted, yet the child may be born
without any serious consequences to its mother or self. But where
the pelvis is considerably narrower than usual, the aid of the
accoucheur will undoubtedly be required.

Cases of this kind may be ascertained by making a careful exam-
ination after the rupture of the membranes ; the forehead not

390

AMERICAN ECLECTIC OBSTETRICS.

being as round as the occiput, will present a flatter surface which
does not fill up the pubic arch, the anterior fontanelle will be found
toward the pubic symphysis, the sagittal suture will be felt passing
backward, in the direction (nearly) of the autero-posterior diam-
eter, to the posterior fontanelle, which latter will be toward the
sacrum. The parietal bones do not overlap one another as usual,
the swelling of the scalp forms less rapidly, and sometimes the
finger can be passed up behind the symphysis pubis and detect the
eyes and root of the nose. If the head has suffered for a long time
from pressure while in the pelvis, there may be some difficulty in
detecting the sagittal suture and posterior fontanelle.

TREATMENT.— We should not interfere in these cases as long
as the uterine contractions are regular, and the head advances,
however slowly. But when the contractions cease, or are not
sufficient to cause any advance of the head, a careful examination
of the parts and of the fetal head must be made to ascertain their
relative proportions, and such aid must he afforded as the circum-
stances of the case may require. On page 319 I have given the
mode of management recommended by Dr. Dewees for the pur-
pose of overcoming the difficulty under consideration, but although
this frequently succeeds, it as often fails, and the practitioner will
then have to resort to the forceps, especially where there is a
failure of uterine power, or, perhaps the perforator may be
demanded; of course, the period for operating will be selected
according to the degree of the difficulty, and the symptoms of the
patient.

Not unfrequently, in occipito-posterior positions, there may be a
delay in the descent of the head, before it has reached the inferior
strait. The membranes having ruptured, the expulsive contrac-
tions are found to cause no advance of the head; an examination
will detect the posterior fontanelle toward one of the sacro-iliac
symphyses, and the sagittal suture may be traced upward and
forward to the anterior fontanelle, which will be located behind
the opposite acetabulum. In cases of this kind, an early inter-
ference is improper, the practitioner should wait until from the
number of strong pains, he is satisfied that they are unable to
advance the head, when, for the purpose of ultimately bringing
the occiput under the pubic arch, he may grasp the cranium
between the thumb and fingers, during the absence of a pain, and
move the face toward the right or left ilium, according as it
originally presented to the right or left acetabulum ; being careful

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 391

not to carry it into the hollow of the sacrum, notwithstanding the
readiness with which so great a change might be effected, because,
should the child's body fail to follow the rotation given to the
head, a serious injury to the neck would, very probably, be the
result; therefore, after having inclined the face to one of the ilia,
the rest of the process must be left to nature. Should the manip-
ulation fail, the face returning to its original position with the
pain, it may be repeated several times until it succeeds. Should
the head become impacted in the pelvic cavfTy before the opera-
tion is attempted, it is very probable that the forceps will be
required to terminate the delivery. (See Occipito-Pubal Position,
page 315, and Occipito- Sacral Position, page 321.)

As a general rule, FACE PRESENTATIONS, may be included
among natural labors, from the fact that they commonly terminate
without any artificial aid; the labors, however, are very tedious
and painful to the mother, and occasion considerable distortion of
the child's features. They are now correctly considered to be
deviations from a head or vertex presentation, and though delivery,
in the greater number of instances, is effected by the natural
powers, still they should always be regarded as mal-positions.

When the head is in a proper state of flexion, the chin touching
or approximating toward the breast, the presentation is always a
normal one of the head, but if there is a premature extension or
departure of the chin from the breast, the tendency will be toward
a face presentation, in which the head gradually becomes bent
backward so far as to ultimately place the face nearly flat across
the oblique diameter of the superior strait, looking down into the
pelvis; and this position almost always occasions a tedious labor,
not unfrequently requiring the aid of the accoucheur.

In relation to the cause of the difficulty in this presentation,
Prof. Meigs remarks: "The fetal head being an oval, five inches
long, from the vertex to the chin, and more than three and a half
inches wide at the widest part, it ought to make no difference, as
far as the mere head is concerned, whether the chin or the vertex
advances first in labor, because, in either case, the same circum-
ferences of the head are presented to the planes through which
they are to be transmitted. The foramen magnum of the occipital
bone beinu* equidistant from the vertex and chin, and situated on
one side of the oval, the peculiar difficulties and hazards of these
labors are attributable, rather to the nature of the articulation by

392

AMERICAN ECLECTIC OBSTETRICS.

which the neck and head are conjoined, than to the form of the
head itself, when advancing with the face downward. The nature
of this articulation is such, that extension of the head can not take
place so well as flexion; hence the requisite dip of the occipito-
frontal diameter is not effected in face cases without difficulty, and
the consumption of much time.

"Let the reader figure to himself the state of the spinal column
of a child, urged on in labor by powerful uterine contractions,
directed to its expulsion with the face in advance. The inferior-
posterior part of the head is pressed against the back of its neck,
or between its scapulae, which could not be the case without bend-
ing the cervical spine backward, like a bow, while the dorsal and
lumbar vertebrae are curved in the opposite direction, causing thus
a double antero-posterior curve, on which, in consequence of the
elasticity of the two arches, much of the expulsive force is vainly
expended; so that, though the power may be as great as in a com-
mon labor, it produces much less effect than in a common labor —
a great part of every pain being expended in reproducing the
greatest amount of curvature ; for the elasticity of the two curves
is such that they are straightened as soon as the pain subsides, at
least in some measure, while the rest of the pain is used in pushing
the face onward." These remarks of Prof. Meigs are undoubtedly
correct, and should be constantly kept in view during a labor of the
kind under consideration.

Tace presentations are usually forehead presentations at first, in
which there is a departure of the chin from the breast at an early
period of labor, and an examination at this time, when the forehead
presents, may mislead the practitioner, who, feeling the firm, glob-
ular presenting brow, rests satisfied that it is a head case, and only
discovers his error when the labor has too far advanced for success-
ful interference. In these cases, it must be remembered that the
forehead presents first ; and as the uterine contractions continue,
extension of the head gradually progresses, so that one eye, then
the other, the nose, the mouth, and the chin, are successively placed
within reach of the finger. Instances have been met with, however,
where the face originally presented at the brim.

The cause of presentations of the face is not satisfactorily under-
stood ; the most common belief is, that it is owing to uterine
obliquity. For instance, if the obliquity carries the fundus far
down on the right side, the vertex, instead of presenting in the
direction of the axis of the brim, will present at a greater or less

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 393

degree of inclination to it, and the expulsive contractions of the
uterus, acting in the direction of its longitudinal axis, will force
the fetus from above downward, and from right to left, so that the
vertex will be made to glance upward into the left iliac fossa, and
a shoulder be presented at the brim, or, the vertex being arrested
at the left border of the superior strait, the forehead will present,
extension will gradually be produced by the continuance of the
pains, and the head be forced backward upon the child's back.
This is, probably, the cause of the major number of these pre-
sentations, yet they are sometimes met with where there is no
obliquity present, and it is very difficult to assign any correct
reasons for their occurrence. Labor coming on before the position
of the fetus is normally established, and excessive coughing, have
been named among the causes, and may occasionally effect a
change in the position of the fetal head, but where a face position
is a primitive presentation, we have no satisfactory idea of its
origination.

DIAGNOSIS. — If the examination be made at an early period
of labor, before the membranes are ruptured, it will be very diffi-
cult to ascertain the character of the presentation, from the fact
that the forehead, which only presents at that time, may readily
be mistaken for a vertex position. But after the extension of the
head is completed, and the membranes have ruptured, the diag-
nosis becomes more easy : on one side of the pelvis we find the
forehead imparting the sensation of a rounded, solid surface,
through which the anterior portion of the sagittal suture may be
felt traversing; carrying the finger slowly along to the opposite
side, in the median line, it meets with a triangular elevation,
increasing in size as it leaves the forehead, and which is the nose ;
at its base will be found two small openings, the nares, which
always look toward that portion of the pelvis where the chin is
situated, and which consequently afford great aid in determining
the position. On either side of this triangular protuberance, at its
apex, the eyes will be felt as two soft tumors, surrounded by a
circle of bone ; and the examination should be gently and carefully
conducted, lest the eyes become seriously injured or even destroyed.
A short distance from the base of the nose will be found the mouth,
conveying the sensation of a transverse fissure bounded by the
superior and inferior maxillary arches.

If a long time has elapsed after the rupture of the membranes,
before the delay in the labor induces the accoucheur to make a
26

394

AMERICAN ECLECTIC OBSTETRICS.

more careful examination, the diagnosis will be more difficult ;
hence the necessity for making a thorough examination immedi-
ately or very soon after their rupture, in all cases of labor. The
tedious progress of the head, and the compression which it under-
goes, cause the face to become very much tumefied : the cheeks
being greatly swollen and at the same time pressed toward each
other, a fissure is formed between them, in which the diagnostic
characters of the face are concealed, and which might lead the
practitioner to confound them with the nates and their intervening
fissure. The lips also swell, become wrinkled, and turn in, pre-
senting a rounded orifice instead of the usual transverse fissure,
and which has been mistaken for the anus, but which may be at
once known by introducing the finger into it, and feeling the
tongue and alveolar processes.

Whenever a case of face presentation is met with, it should be
announced to the friends of the patient, together with the proba-
bility of considerable distortion of the features of the child when
born, else its frightful appearance may be attributed to some
improper violence, or perhaps want of skill, on the part of the
medical attendant. If the labor is a tedious one, the appearance
of the new-born child will be very repulsive, its face swollen, the
eyelids in a tumefied state, aud one or both eyes closed, the nose
also swollen to an enormous extent, and the whole features pre-
senting a dark or livid appearance, scarcely being recognized as
the countenance of a human being. These appearances generally
pass off in a few days. Sometimes, when the labor is very tedious,
the congestion or stasis of the blood extends even to the brain,
creating an apoplectic condition, and occasionally the death of
the child.

Although the face may present in various positions, yet, for
practical purposes, the two heretofore named are all-sufficient, viz. :
the left mento-iliac, and the right mento-iliac. And these names will
apply to the positions when the chin is to the left or right side of the
pelvis, whether they be directly transverse, as more frequently
happens, or have the chin turned more or less anteriorly near the
body of the pubic bone, or posteriorly toward the sacro-iliac
symphysis. So that, for instance, should the face be placed in the
pelvis exactly in a transverse position, with the chin to the right
ilium, or obliquely with the chin toward the right sacro-iliac
symphysis, or toward the right pubic bone, the obliquity of the
position does not, in either case, interfere with its claim as a right

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 395

me nto-iliac position; and so of the left, when the chin is placed
at the left side of the pelvis. The transverse positions of face
cases being the most frequent, are regarded as the primitive posi-
tions, from which the oblique positions are derived during the
progress of labor.

1. MECHANISM OF LEFT MENTO-ILIAC POSITION.

This position is not so frequent as the right mento-iliac, and is
usually termed the second position ; but for the purpose of pre-
serving regularity, and aiding the student in recollecting all
positions, as being successively to the left, right, and front, I
have given it as the first position. As a general rule, previous to
the rupture of the membranes, the forehead will be found near
the center of the superior strait, the chin being placed at the left,
and the anterior fontanelle at the right side of the pelvis. The
mento-bregmatic diameter of the fetal head corresponds to the
transverse diameter of the upper pelvis, the bi-temporal of the
former to the antero-posterior of the latter, and the occipito-
frontal diameter of the head is in a direction with the axis of the
superior strait. The back of the child is toward the right side of
the mother, an'd its abdomen toward her left side; its left side is
in front, and its right behind ; the feet are above and to the left.
{Fig. 54.) (Figures 54, 55, and 56, represent the right mento-iliac
positions, but as far as the mechanism of labor is concerned, they will
answer to illustrate the left mento-iliac positions.)

As soon as the membranes nip- pIG 54

ture, and the expulsive contractions
commence, the head being in a state
of moderate extension, and meeting
with resistance, forced extension takes
place, which gradually causes the
face to present at the superior strait
instead of the forehead, as hereto-
fore explained. The fronto-mental
diameter of the head now corre-
sponds, instead of the mento-breg-
matic, to the transverse diameter of
the brim; the bi-temporal to the
antero-posterior, and the fronto-
mental circumference offers to that
of the superior strait; the body of the child remains unchanged.

396

AMERICAN ECLECTIC OBSTETRICS.

and a line drawn from the upper lip of the child to the posterior
fontanelle, will give the direction of the axis of the upper strait.

{Figure 55.) As soon as the exten-
sion of the head is completed, it
engages in the pelvic cavity and
descends as low as possible, or as
far as the length of its neck will
permit. The depth of the lateral
part of the pelvis is three inches,
and as the length of the neck does
not reach this measurement, the
descent of the head is limited, and
must cease at some point short of
the pelvic floor; for if it advanced
further, the head and part of the
child's breast would be contained in
the pelvic cavity at the same time, a
thing not ordinarily possible. The resistance of the soft parts
and the inclined pelvic planes cause the head to rotate, carrying
the chin from left to right, in front and behind the s}7mphysis
pubis, while the forehead passes from right to left, backward into
the hollow of the sacrum. Should the chin fail to rotate toward
the symphysis pubia, the labor will be immensely difficult, if not
altogether impossible, because the occipito-mental diameter of the
head must, toward the termination of the process, offer to the
antero-posterior of the inferior strait, before the head can be born.
The descent and rotation of the head being now completed, the
process of flexion commences, the pains push the body of the
inferior maxillary bone, and finally the fore-part of the neck
against the posterior surface of the pubes, which arrests its pro-
gress, and, in consequence of the impossibility of any further
descent of the neck, the expulsive force is exerted, at this time,
principally upon the occiput, and the head is gradually delivered
by successively presenting at the vulva, first the chin, then the
mouth, nose, eyes, forehead, anterior fontanelle, posterior fonta-
nelle^and occiput, which latter has to traverse the whole anterior
sacral surface, a distance of about five inches and a quarter; and
during the delivery the perineum becomes greatly distended. As
the chin emerges under the pubic arch, there is not a correspond-
ence of the whole measurement of the occipito-mental diameter
of the fetal head with the antero-posterior diameter of the inferior

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 397

strait, as shown in the linear representation of the various degrees
of the head's disengagement, in Fig. 56, in which, while the head
is in the same position, the occiput is represented as departing
more and more from the shoulders.
The head being disengaged, the motion
of restitution follows, placing the occiput
to the right side of the mother, and
which, as in vertex presentations, is
owing to the engagement of the
shoulders at the brim. The head beine
delivered, the expulsion of the body is
effected as in ordinary vertex positions.
It must be recollected, that in this posi-
tion the left side of the child's face is
anterior and rather more depressed than
the other side upon entering the superior
strait, and on making an examination, the finger comes in contact
with the left eye or malar bone, upon which part is formed the
primary tumor. Nsegele observes that the swelling forms " first
upon the upper part of the" left "half of the face, which in this
species of a face presentation (left mento-iliac) is always situated
lowest." "If the progress of the head through the external pas-
sages be unusually rapid, this is the only tumefaction observed ;
but if it advances slowly, and the head remains a long time in the
cavity of the pelvis before it actually enters the vagina, the
inferior half of the left side of the face, viz.: part of the left cheek,
will be remarked after birth as being the principal seat of the
swelling," a secondary tumor being formed there.

It is sometimes the case, especially when the chin is situated
rather posteriorly, that previous to the movement of rotation a cer-
tain degree of flexion takes place, which causes the forehead to
descend to the pelvic floor, after which the chin rotates to the
pubic symphysis, and the delivery is accomplished as in the other
instances.

2. MECHANISM OF RIGHT MENTO-ILIAC POSITION.

This is the most frequent of the face presentations, and is usually
named the first position. The positions of the diameters of the
fetal head, and their relations with the pelvic diameters, will be
the same as in the left mento-iliac cases; the exceptions are,
that in the present position the forehead corresponds to the left

398

AMERICAN ECLECTIC OBSTETRICS.

iliac fossa, and the chin to the right iliac fossa ; the child's back is
toward the left side of the mother, and its abdomen toward her
right side ; its right side is in front, its left behind, and the feet are
above and to the left. {Fig. 54.) The mechanism in this case
is precisely similar to the one just described, with the exception
that rotation takes place from right to left.

TREATMENT. — Although face presentations are accidents, or
deviations from vertex positions, yet, as a general rule, the natural
powers will be found adequate to safely terminate the labor, and
the practitioner must not interfere as long as the pains are regular
and energetic, the parts cool, the patient free from febrile symp-
toms, and the head advancing, however slowly. If, however, the
pains become feeble and insufficient, or accidents should occur,
then interference will be required. Turning was formerly recom-
mended by authors, but from the difficulty, and the danger to both
the mother and child, attending this operation, it is at the present
day very rarely attempted, and is not advised by recent authorities.

Could we positively know the presentation and position of the
head, at an early stage of the labor, previous to its descent into
the pelvic cavity, we might possibly, when required, restore it to
a normal situation, by the manipulation recommended by Dr.
Dewees :

" In the first and second positions, we must have the concurrence
of the following circumstances, before we attempt the reduction of
the head ; first, the uterus must be sufficiently open to permit the
hand to pass, with little or no difficulty; second, the head must
not have entirely passed the superior strait ; third, the waters
must have been recently expended. If these advantages combine,
after having the woman properly placed, a hand must be passed
into the uterus ; and the choice of the hand is a matter of the first
consequence to the success of the operation : the governing rule
is simple, and easily remembered ; namely, the hand which is to
the side on which the vertex and forehead are placed ; that is, in
the first, the right hand must be used; because, when before the
patient, the right hand offers to the left side of her, or the pelvis ;
if the second be the position, the left hand must be employed,
for a like reason. [These positions are reversed, in my arrange-
ment. K.]

"In the first position of the face, we pass the right hand into
the uterus in such a manner as shall put the back of the fingers
to the posterior part of the pelvis, or before the left sacro-iliac

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 399

symphysis, and place them on the side of the head, while the
thumb is pressed against the opposite side ; the head is then to be
firmly grasped, and raised to the entrance of the superior strait.
When the head is thus poised, the extremities of the fingers are
to be carried over the vertex, while the thumb is moved to the
center of the upper part of the forehead; the fingers are then made
to draw the vertex downward, while the thumb tends by its pres-
sure, to carry the face upward, thus executing a compound action
upon the head. All this, it should be remembered, must be exe-
cuted in the absence of pain ; if we find, when pain comes on,
that the vertex moves sufficiently downward, and the face upward,
to give assurance it will now descend, we may withdraw the hand,
and trust the rest to the action of the uterus. But if, on the con-
trary, upon the accession of the pain, we find the face still has
a tendency downward, we may be certain that the reduction is
incomplete ; and we must again and again attempt it, in the
absence of pain, if it be necessary : for, under the circumstances
I have stated, we are pretty sure of success under a well-directed
management.

" In the second position, we employ the left hand, under the
conditions I have stated for the first, and act in every respect as
directed for that presentation."

But in pursuing the method here advised, we must recollect,
that while the head is above the superior strait, the dilatation of
the os uteri is seldom sufficient to allow the introduction of the
hand into the uterus for the purpose of effecting the change, and
the enlargement of the orifice by dilatation continues to extend
only as the presenting part of the child descends; consequently,
the above operation is only a bare possibility, but which it may be
necessary sometimes to attempt.

Most generally, the existence of a face presentation is not ascer-
tained until the part has so far descended into the pelvic cavity,
as to render it impossible, either to push it into the upper pelvis,
or effect the above operation of bringing down the vertex. In
such instances, it will become necessary to be guided by the gen-
eral principle of obstetrics, to wait until symptoms present which
indicate the need of artificial aid, and then make use of those
means best calculated to overcome the difficulty. The vectis will
probably be found the most appropriate instrument in a majority
of cases ; if the head be low down, the forceps may, perhaps, be
employed advantageously — though the selection of the instrument

400 AMERICAN ECLECTIC OBSTETRICS.

must depend upon the peculiar character of the case, and the judg-
ment of the practitioner. If these means fail, the only resource
is craniotomy. In these cases, much patience, gentleness, and
sympathy are required on the part of the practitioner, who must
encourage his patient from time to time, and endeavor to keep her
from becoming depressed and discouraged.

I have not, heretofore, named the only and positive rule to be
observed in all face cases, whatever may be their position, viz.: to
bring the chin to the pubic arch, so that the original flexion of the
head may be restored as soon as possible after the delivery of the
chin ; and in by far the greater number of instances in which this
rotation is effected, the labor will terminate without any formid-
able results. If this rotation can not be effected, and the forehead
should present at the pubic symphysis, the practitioner must make
use of means the most applicable to the emergency. Prof. Meigs
remarks, that in all face presentations, "the great doctrine is, to
bring the chin to the pubic arch, because the chin, being the men-
tal extremity of the five inch mento-occipital diameter, may escape
by gliding an inch downward, behind the symphysis pubis;
whereas, if it be directed backward to the sacrum, it must slide
five inches down the sacrum and coccyx, and from three to three
and a half inches over the extended perineum before it can be
born ; but, five inches and three inches make eight inches. The
child's neck is not eight inches long. Therefore, before the chin
can slide down the sacrum, and off the anterior edge of the
extended perineum, a good part of the child's thorax must be
pressed or jammed into the excavation along with the head, the
vertical diameter of which alone is more than three and a half
inches." This is a correct representation of the matter, and the
practice alluded to, of bringing the chin to the pubic arch, is the
one at present universally pursued by all scientific accoucheurs.

EAR PRESENTATIONS, or Presentations of the Side of the
Head, occur very rarely ; they are considered as deviations from
the vertex presentations, and occasioned by an undue obliquity of
the uterus, or, perhaps in some instances, an abnormal amount
of liquor amnii. In 20,517 instances they have been met with
only 6 times, five of which were of the left side of the head, and
the remaining one of the right. They are known by the presence
of an ear at the superior strait. Each side of the head may present
in three different positions, which are determined by the relations

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 401

of the ear to the maternal pelvis ; they have been classified as
follows :

PRESENTATION OF THE RIGHT SIDE.

1st Position Lobulo-pubal

2d Position Right lobulo-iliac.

Zd Position Left lobulo-iliac.

PRESENTATION OF THE LEFT SIDE.

1st Position Lobulo-pubal.

2d Position Right lobulo-iliac.

Zd Position Left lobulo-iliac.

DIAGNOSIS. — As there is no part of the fetal body likely to be
confounded with the ear, its detection may be accomplished with but
little difficulty. The ear may be felt, with the surrounding bony
head ; we know the face to be situated anterior to the tragus, and
the occiput to be behind the helix, or circumference of the ear, so
that from these marks we may readily determine the position of the
head.

In the LOBULO-PUBAL POSITION, of the Right Side of the
Head, the lobe of the ear, as well as the base of the cranium, look
toward the pubes, the long diameter of the external ear presents in
the direction of the antero-posterior diameter of the superior strait,
the vertex is at the promontory of the sacrum, the convexity of the
helix and the occiput are directed toward the left side of the pelvis,
and the face and tragus toward the right side. The child's back is
toward the left side of the mother, its front toward her right side,
its left side looks posteriorly, its right side anteriorly, and its feet are
above and to the right.

This is a deviation of a left *occipito position, produced by an
anterior obliquity of the uterus, and should be remedied by placing
the patient upon her back, with the pelvis somewhat elevated, rais-
ing the fundus upward and backward, and then applying a bandage
firmly around the abdomen. The obliquity removed, the vertex
passes in front of the sacral promontory, the head rises, and gradu-
ally recovers its original left occipito .position, and the delivery is
terminated naturally.

In the EIGHT LOBULO-ILIAC POSITION, of the Right Side
of the Head, the lobe of the ear looks toward the right side of the
pelvis, the long diameter of the external ear presents in the direc-
tion of the transverse diameter of the pelvis (or nearly so), the
vertex is at the left iliac fossa, the convexity of the helix and the
occiput are directed toward the pubes, and the face and tragus

402

AMERICAN ECLECTIC OBSTETRICS.

toward the sacrum. The child's back is anteriorly, its front pos-
teriorly, its left side is toward the left of the mother, its right side
toward her right, and the feet above, and toward her left, and back.

This is, likewise, a deviation from a left occipito position, occa-
sioned by an extreme right lateral uterine obliquity, and should be
managed by placing the female on her left side, elevating the fundus
v upward and to the left, and applying the bandage as before. The
obliquity removed, the head engages in the brim, and the delivery
terminates naturally.

In the LEFT LOBULO-ILIAC POSITION, of the Right Side of
the Head, the lobe of the ear is toward the left side of the pelvis, the
long diameter of the concha is parallel, or nearly so, to the pelvic
transverse diameter, the vertex is at the right iliac fossa, the con-
vexity of the helix and the occiput look toward the sacrum, and the
face and tragus toward the pubes. The child's back is toward the
maternal back, its front anteriorly, its left side toward the right of
the mother, its right toward her left, and the feet above, and toward
her right, and front.

This is a rare presentation, and is a deviation from a left occipito-
posterior position ; it is produced by an extreme left lateral obliquity.
The treatment is similar to the previous instances ; the female must
be placed upon her left side and bandaged ; the vertex engages in the
brim, and the labor terminates as in a left occipito-posterior position.

In these lateral obliquities, the object of the bandage is to prevent
the uterus, after a change in its position has been effected, from
returning to its original inclination.

When the LEFT SIDE OF THE HEAD presents, the general
relations with the pelvis are the same as in the preceding instances,
but the partial relations are inverted. Thus, in the LOBULO-
PUBAL POSITION" of the Left Side of the Head, the lobe of the
ear is toward the pubes, the long diameter of the concha corre-
sponds with the pelvic antero-posterior diameter, and the vertex is
at the sacral promontory ; but the convexity of the helix and the
occiput are directed toward the right side of the pelvis, and the face
and tragus toward the left. The child's back is toward the right
side of the mother, its front toward her left side, its left side looks
anteriorly, its right posteriorly, and its feet are above and to the left.

In the RIGHT LOBULO-ILIAC position of the left side, the
lobe of the ear will be directed toward the right side of the pelvis,
the vertex toward the left, the occiput and convexity of the helix
toward the sacrum, and the face and tragus toward the pubes. The

DIFFICULT LABOR — FROM MAL-POSITION OF THE HEAD, ETC. 403

fetal back will be directed backward, its anterior plane in front, its
left side to the right of the mother, its right to her left, and its feet
above, toward her left and front.

In the LEFT LOBULO-ILIAC position of the left side, the
lobe of the ear is to the left side of the pelvis, the vertex to the
right, the convexity of the helix toward the pubes, and the tragus
toward the sacrum. The fetal back is directed to the front of the
mother, its front to her back, its left side to her left, its right side
to her right, and its feet above, toward her right, and back. All
these mal-positions are to be rectified upon the general principles
described above : if these fail, efforts may be made to bring down
the vertex, when the head is at the brim, by a manipulation
(somewhat similar to that recommended by Dr. Dewees for restor-
ing face presentations to vertex, and which is extracted from his
Obstetrics on page 398 of the present work), in which the head
will have to be slightly elevated, and then have lateral or anterior
pressure or pushing made upon the vertex in a direction toward
the chin, followed by a drawing down of the vertex. It may be
best performed, after reduction of the uterine obliquity and the
application of the bandage, by placing the patient on her hands
and knees, with the hips elevated and the shoulders depressed,
which position will, in a measure, remove the weight of the child's
head from the brim, and thus facilitate the operation. This, how-
ever, will seldom be needed, and may frequently fail. In cases
requiring further aid, it will be prudent to wait, in order to ascer-
tain the adequacy of the natural efforts ; and should these fail, or
the usual symptoms demanding interference present themselves,
the delivery must be terminated by the vectis, the forceps, or the
perforator, as the exigencies of the case may require. Turning
has been recommended, previous to the rupture of the membranes,
when the os uteri is considerably dilated, soft, and dilatable, and
may possibly be advantageous in some cases; but after the mem-
branes have given way, it must not be attempted.

Labor may be rendered difficult, by a COMPOUND PRESENT- *
ATIOIST, in which one of the Extremities Presents with the Head, as
a hand, arm, or foot. While the fetus is within the uterus, its
position is generally with the arms across the chest, and sometimes
with one or both hands against each ear on the sides of the head :
in these latter instances, when the membranes rupture and the
liquor amnii is discharged, one or both hands, or even the whole

404

AMERICAN ECLECTIC OBSTERICS.

arm, may descend with the head, and this is more apt to occur
when the membranes have ruptured prematurely. These com-
pound presentations are frequently occasioned by a large pelvis,
and when such is the case, the delivery may be safely accomplished
without assistance. But when the pelvis is small, the presence of
the limb or hand increases the diameter of the head, and prevents
its descent into the cavity; and if the uterine contractions are
energetic, an arrest or impaction of the head may take place at
the superior or inferior strait, and, perhaps, terminate fatally.
When the foot, hand, or arm presents with the head, it must be
pushed back with two or three fingers, during the absence of a
pain, and held there until one or more subsequent pains causes the
head to descend so low as to prevent any further falling of the
extremity, after which the labor must be left to the natural
powers. In performing this operation, the accoucheur must be
exceedingly careful not to draw the arm or hand down, nor to
displace the head, as he might thereby convert the case into a
shoulder presentation. In order to effect a successful manipulation
of this kind, the whole hand will require to be introduced into the
vagina, and partly through the os uteri. The operation should
not be attempted until the os uteri is sufficiently dilated, and the
expulsive pains have commenced; for if it be attempted in the first
stage of labor, there will be more danger of displacing the head,
and of producing an unnecessary degree of irritation of the cervix
uteri, and the practitioner should be governed by this rule, even
should the membranes have become prematurely ruptured. The
upper extremities will generally be more easily returned, on
account of their less volume, than the lower.

If the limb can not be returned, the practitioner must wait, as in
other instances, until satisfied that the natural efforts are inade-
quate to terminate the labor, and unfavorable symptoms begin to
manifest themselves, when it will become necessary to turn, or
employ the forceps, or perform craniotomy, according to the
peculiar circumstances of the case. It is impossible to lay down
any special management of these cases: each one will have its
own peculiarities, which, together with the tact and judgment of
the attending accoucheur and his medical advisers, must determine
the course to be pursued.

Sometimes both the hands and feet will present together,
when it may become necessary to bring down the feet (and more
especially when the feet present with the breech), and thus convert

DIFFICULT LABOR — FROM MAL -POSITION OF THE HEAD, ETC. 405

it into a footling case. In doing this, the practitioner can not be
too careful in his examination, lest he occasion a descent^ot the
arm or hand, or bring down a hand instead of a foot. Should
there be a prolapse of the cord, in connection with these limb
presentations, the case becomes still more serious, as far as the
child is concerned; and the management should be in accordance
with the rules hereafter given for this complication — hastening
the delivery as soon as the pulsations are found to diminish.

CHAPTER XXXII.

ON PRETERNATURAL LABOR. PELVIC PRESENTATIONS.

PRETERNATURAL LABOR, is where the head does not
present, as in shoulder or breech presentations ; prolapsus of the
umbilical cord, plurality of children, and monsters, are likewise
included in this class. Females frequently have preternatural pre-
sentations in several successive labors, and it is impossible to assign
any satisfactory cause for them. They can not be the results of
violent shocks experienced during gestation, for they more fre-
quently occur in cases where the period of pregnancy has passed
free from any accidents. Dr. Denman, in 1795, remarked: "It
seems doubtful, therefore, whether we ought not to exclude acci-
dents as the common causes of these presentations, and search for
the real cause from some more intricate circumstance; such as, the
manner after which the ovum may pass out of the ovarium into
the uterus ; some peculiarity in the form of the cavity of the uterus
or abdomen ; in the quantity of the waters of the ovum at some
certain time of pregnancy ; or, perhaps, in the insertion of the
funis into the abdomen of the child, which is not in all cases con-
fined to one precise part, but admits of considerable variety." At
the present day we are no further enlightened on this point than
were the profession in his time. Some instances may, probably,
be owing to uterine obliquity, or to peculiarity of the formation of
the pelvis; thus, in three successive labors, I have delivered the
same female by turning, each instance being a shoulder presenta-
tion in the second left cephalo-iliac position. This person, when
young, had been employed to take care of children, and was in the
habit of carrying them the greater part of the time on one hip:

406

AMERICAN ECLECTIC OBSTETRICS.

the crest of the left ilium was from an inch to an inch and a half
higher than that of the right, when she stood erect. Whether
this irregularity was owing to the manner in which she held the
children during her youth, or whether it was the occasion of the
shoulder presentations, I arrrnot prepared to state : it is very diffi-
cult, in such obscure matters, to obtain, from one or two incidents
connected with them, more than suggestions.

During gestation it is a very difficult, if not an impossible mat-
ter, for females to determine with certainty a preternatural posi-
tion : they may suspect that such is the case, and may almost be
positive of it, from certain circumstances not usual with them
during this period ; yet although their fears are occasionally con-
firmed when the labor comes on, they more frequently find them-
selves mistaken. Nor is it a more easy task for the accoucheur
■to ascertain, during pregnancy, a preternatural presentation,
although some have professed an ability to decide by the sensation
imparted to the hand, upon an abdominal exploration over the
uterus at an advanced period ; also, by the situation at which the
pulsations of the fetal heart are heard. But I place no confidence
in these methods, either singly or combined. It is not until the
labor has actually commenced, that we can learn with positivenees
the presentation of some other part than the head. When the
membranes do not present the globular form usual in head pre-
sentations, but may be felt protruding into the vagina, having
a peculiar, elongated, or conical-pointed shape, we may suspect
a preternatural presentation, though this has been occasionally
met with in vertex positions. " Sometimes, before the os uteri is
much dilated, the membranes, filled with liquor amnii, pass into
the upper part "of the vagina, and form a considerable sac with
a narrow neck." — [Lee.) A spontaneous and premature rupture
of the membranes, is generally a diagnostic sign of preternatural
presentation, in which case an internal examination should be
made as soon as possible, in order to determine its character. If,
previous to the rupture of the membranes, when the os uteri is
somewhat dilated, we can not feel the presenting part, or, if felt,
it is more movable, less smooth, globular, and resisting, than
the head, a preternatural presentation may be suspected : such
instances must be closely watched, and great care be had not to
rupture the membranes, as an early discharge of the liquor amnii
will render the operation of turning very difficult, or entirely
impossible. Sometimes a foot, or a hand, or the umbilical cord,

PRETERNATURAL LABOR — PELVIC PRESENTATIONS.

407

may be felt and clearly recognized through the membranes, but
usually the presenting part can not be ascertained until these have
ruptured.

In all labors, it is of great importance that the practitioner
should ascertain, as early as possible, the nature of the presenta-
tion, in order that, where assistance is required, it may not be
delayed until the golden opportunity for saving mother and child
is lost. And, whenever he is positively satisfied that some other
part than the head presents, he should inform the nurse, or friends
of the patient, of the fact.

Presentation^ of the head are by far more common than those
of any other part of the child, and have, therefore, been arranged
under the head of natural labors; other presentations, being less
frequently met with, will be considered under the present head of
preternatural labors. A preternatural labor may terminate by the
natural powers, but the labors are, as a general rule, slow and
tedious, more painful to the mother, and more hazardous to the
child than in head presentations; accidents are, likewise, more apt
to take place, requiring artificial assistance.

PRESENTATIONS OF THE PELVIC EXTREMITIES, as of
the breech, knees, or feet, belong to preternatural labors. In the
majority of these cases the delivery may be safely effected by the
natural powers, in consequence of which, some eminent authors
have included them among natural labors; but I consider the
present arrangement as being more in accordance with the nature
of the cases, and better adapted to facilitate an acquaintance with
them. From the statistics given on page 305, which are the
recorded statements of British, French, and German accoucheurs,
it will be observed that the danger to the child is much greater in
pelvic presentations than in those of the head, and that the cases
in which the inferior extremities present, are more hazardous than
in true breech deliveries.

The principal danger in these breech labors is to the child ; the
soft passages are not so thoroughly dilated by the body as by the
head, because the breech, even with the legs turned up, does not
present so great a bulk in circumference or diameters, as the head,
and consequently, when the head is in the pelvic cavity, it can not
descend until the parts become still further distended and better
adapted for its advance. This renders the delivery of the head
slow and tedious, during which, the cord may be exposed to a

408

AMERICAN ECLECTIC OBSTETRICS.

pressure resulting in fetal asphyxia; or the same result may ensue
from detachment of the placenta, before the head has passed the
outlet; or by pressure upon the placenta when situated between
the fetal head and the uterine walls ; in either of which instances,
the utero-placental circulation is suspended. The first (compres-
sion of the cord) is a more common cause of the child's death in
footling presentations; the latter, in those of the breech. When
the thighs are not flexed upon the abdomen, the child being
delivered by the feet or knees, the head will advance more slowly,
in consequence of the greater resistance offered to it, than where
the limbs are turned up, and the greater delay and longer-con-
tinued pressure upon the cord, renders this species of pelvic
deliveries more fatal to the child.

The danger to the mother in these cases, is owing entirely to a
delay in the second stage of labor beyond a certain period, to
injuries of the soft parts from compression, or improper efforts to
facilitate the child's expulsion, and to narrowness or deformity of
the pelvis.

DIAGNOSIS. — Previous to labor, a pelvic presentation may
sometimes be ascertained, especially among women whose abdo-
minal walls are thin, soft, and flaccid, by feeling the fetal head in
the upper part of the uterus, inclined either toward the right or
left side ; if auscultation be resorted to, the pulsation of the fetal
heart may be heard in the upper portion of the abdomen,* either
above, or on a level with the umbilicus; if a vaginal exploration
be made, it will be found difficult to reach or distinguish the pre-
senting part, though, sometimes, instead of the hard, globular
tumor felt in head presentations, a small tumor, the foot, may
be felt, and ballotted.

But the most certain method of diagnosis is during labor, in the
absence of pain, when the presenting part can be felt. The breech
may be known from the head, by its soft and fleshy feel, and by the
absence of sutures and fontanelles ; it is not so round or so hard
as the head. Upon some part of the anterior surface will be felt
the hard, resisting trochanter; passing the finger carefully around,
the tuberosities of the ischia may be detected, also the fissure
between the nates ; at the bottom of this fissure are found the
most important signs, as the sacrum, coccyx, anus, and external
genital organs; and the anus may be detected from the mouth, by
the difficulty, if not impossibility, of introducing the finger into it.

PRETERNATURAL LABOR — PELVIC PRESENTATIONS. 409

The presence of the coccyx, not only assists us in determining the
character of the presentation, but also that of the position,
because its point or apex is always directed toward the side of the
maternal pelvis corresponding with the child's abdomen. The
presence of the meconium, which has been noticed by some writers
as a diagnostic sign, is really of little value, as it is frequently met
with in head presentations, and also occurs as a sign of the child's
death.

Having become positively certain that the breech presents, it
should be named to the husband, nurse, or some relative, but great
care must be taken to conceal it from the patient, lest it impart a
shock to her mind which may suspend or retard the labor for
several hours. The communication should be made to the husband
in a separate room, and all the dangers to which the child is
exposed, fully made known, so that in case it be still-born, the
skill or ability of the medical attendant may not be called into
question. Should the sex of the child have been ascertained
during the examination, it must not be made known to any one,
lest it reach the patient's ears, and effect an unfavorable influence
over the progress of the labor, by the disappointment it might
occasion should it be different from the one desired.

By a reference to page 305, it will be seen that four positions are
given, in any one of which the breech may present ; and which
positions are ascertained by the coccyx, ischiatic tuberosities,
genitals, etc., and named according to the situation of the back or
sacrum of the child.

1. MECHANISM OF LEFT SACRO-COTYLOID POSITION.

In this position the sacrum of the fetus faces the maternal left
ilium anteriorly, while the hips or bi-trochauteric diameter are
parallel with the right oblique diameter of the superior strait, or,
with its antero-posterior diameter ; the abdomen, and posterior
part of the fetal thighs flexed upward, are toward the right ilium
posteriorly, its left side is in front, and its right side to the back
of the mother; the head is slightly flexed on the chest, and
inclined to the right and posteriorly.

As soon as the membranes rupture, a large amount of the liquor
amnii escapes, and the presenting part, which was previously high
up, engages in the brim, and its position can now readily be ascer-
tained. The hips usually engage in the direction of the antero-
posterior diameter, but if the pelvis be small, or the child unusually

410

AMERICAN ECLECTIC OBSTETRICS.

large, tliey will take the direction of the right oblique diam-
eter. {Fig. 57.) As the uterine contractions continue, the nates
Yia, 57. descend into the pelvic cavity until

they arrive at the inferior strait, the
left or anterior nates being the
lowest. At this point rotation takes
place, and the child's left hip is car-
ried to the left, toward the pubis,
while its right rotates to the right
toward the hollow of the sacrum.
{Fig. 58.) The left hip appears first
at the vulva, under the symphysis
pubis, maintaining its position there,
while the right hip is made to grad-
ually traverse the hollow of the sac-
rum, and inner perineal surface, de-
scribing an arc of a circle around the
left hip as a center. In some cases the left hip, during this motion
of the right, ascends behind the pubic symphysis.

Fig. 58. While the right hip is passing

over the posterior wall of the pel-
vis, the body of the child becomes
curved laterally on its anterior side,
so as to accommodate itself to the
curvature of the pelvic cavity. {Fig.
59.) This lateral curvature contin
ues until the body is expelled;
though as the parts are disengaged
they recover their original position.

As the right hip advances toward
the posterior commissure, the bis-
iliac diameter of the fetus corre-
sponds with the pelvic antero-poste-
rior diameter, and the process of
restitution takes place after the delivery of the pelvis, placing it
in its original diagonal position ; though frequently this oblique
position is retained throughout delivery. The hips having been
delivered, the fetal breast engages in the excavatiou, and as the
body descends, the inferior extremities fall out. The shoulders are
usually in an oblique position when they arrive at the inferior
strait, provided they have not partaken of the rotation of the

PRETERNATURAL LABOR — PELVIC PRESENTATIONS.

411

hips, as this movement may either be partial, or participated in
by the whole body. When they are in the oblique diameter of the
pelvis, rotation is effected, which places *. 59

the left shoulder under the pubic symphy-
sis, and the right in the sacral concavity;
the left shoulder remains at the pubes,
while the right passes over the anterior
face of the sacrum, coccyx and perineum,
when both are delivered. As is the case
with the hips, the left shoulder sometimes
ascends behind the symphysis pubis, during
the passage of the right over the posterior
pelvic wall, instead of appearing first at
the vulva. If the shoulders descend in
an oblique position, the right one will be to the left and back, and
the left to the right and front, consequently rotation will carry the
left shoulder from right to left. The right or posterior shoulder is
generally delivered the first.

The arms are usually applied closely to the thorax, and are thus
delivered ; but it sometimes happens, that one or both of them get
up along the sides of the head, rendering the delivery of the head
very difficult, and requiring artificial interference. This may be
occasioned by the smallness of the pelvis, or the unusual size
of the child; but it more commonly arises from an imprudent
traction made by the accoucheur on the pelvic extremity, in order
to facilitate the delivery, and which improper interference may
still further increase the difficulty of the labor, by effecting an
extension of the head. In ordinary instances, where one arm has
been thrown up by the side of the head, it will most commonly be
the one behind the pubic symphysis.

"While the shoulders are being disengaged, the head, usually well
flexed upon the thorax, has entered the superior strait in the direc-
tion of its left oblique diameter, the forehead being toward the
right sacro-iliac symphysis, and the occiput toward the left acetab-
ulum, which flexion and diagonal position it retains until it has
reached the inferior strait. At this strait, the relation of the pelvic
diameters with those of the fetal head will vary according to the
degree of flexion. If the flexion be moderate, the occipito-frontal
diameter will be parallel to the left oblique of the strait, and the
bi-parietal to the right oblique, while the trachelo-bregmatic diam-
eter will very nearly correspond with the axis of the inferior

412

AMERICAN ECLECTIC OBSTETRICS.

strait. But if there be a greater degree of flexion, the sub-occipito-
bregmatic will correspond with the pelvic left oblique diameter,
and the axis of the lower strait will very nearly pass in the direc-
tion of the occipito-mental diameter.

Upon arriving at the inferior strait, the head undergoes the
movement of rotation, by which the face is carried into the hollow
of the sacrum, the occiput behind the symphysis pubis, and the neck
under it ; the sub-occipito-bregmatic diameter is placed nearly in
correspondence with the pelvic antero-posterior. At this period,
the head is nearly, or altogether in the vagina, and consequently
the contractions of the uterus exert but little or no expulsive influ-
ence upon it ; the further progress of the head is, therefore, to be
effected by the contractions of the abdominal muscles. As the
neck is- situated firmly against the pubic arch, preventing the
descent of the occiput, the contractions will occasion the head to
become more and more flexed upon the chest, and while this
motion is taking place, the chin, face, forehead, and posterior fon-
tanelle, traverse the internal face of the sacrum and perineum, and
successively appear in front of the posterior commissure of the
vulva, while the occiput is the last delivered.

[2. MECHANISM OF RIGHT SACRO-COTYLOID POSITION.

In this position the sacrum of the fetus faces the maternal right
ilium anteriorly, while the bi-trochanteric diameter is parallel with
the left oblique diameter of the superior strait, or, with its antero-
posterior diameter; the abdomen, and posterior part of the fetal
thighs flexed upward, are toward the left ilium posteriorly, its
right side is in front, and its left side to the mother's back ; the head
is flexed and inclined to the left and posteriorly.

The mechanism in this position is precisely similar to the one
just described, with the exception of an inversion of the relations
of the parts. The right hip rotates from right to left, and is the
one placed at the pubic arch, while the left traverses the posterior
wall of the pelvis. The right shoulder rotates from left to right
to reach the pubic arch, and the head engages in the cavity with
the occiput toward the right acetabulum, and the forehead toward
the left sacro-iliac symphysis.

3 and 4. MECHANISM OF SACRO-PUBIC AND SACRO-SACRAL POSITIONS.

These positions are vary rare, and are not recognized by some
authors. When they do occur, they must be converted either natu-

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 413

rally or artificially, into the first or second position, by rotation, or
the labor can not proceed.

TREATMENT OF BREECH PRESENTATIONS.

In all presentations of the pelvic extremity, the cases should be
left to the natural powers, unless accidents occur imperatively call-
ing for assistance, and this point can not be too strongly urged upon
the student. The mere fact of a child being born, " doubled up" as
in a breech presentation, does not necessarily presuppose interfer-
ence, especially when we call to mind the diameters of the parts,
teric and bis-iliac, are smaller than the bi-parietal diameter of the
The largest diameters of the fetal breech, as the bi-trochan head, or
the bis-acrominal diameter. When a presentation of this kind is met
with, no attempts should be made to bring down the feet and infe-
rior extremities, unless there be proper cause for so doing; to do
otherwise is bad, meddlesome practice. When the breech descends
with the limbs flexed upon the abdomen, the labor proceeds slowly,
in consequence of the yielding character of the presenting parts,
which, not being firm and resisting, like the head, give way, to a
certain extent, during each pain, and thus require a longer time to
render the soft parts of the mother sufficiently yielding. But this
protractedness in the deliver}" of the fetal pelvis, is rather to the
child's advantage; for the maternal parts become so thoroughly
dilated and yielding thereby, that the head passes without any
difficulty, a few efforts of the patient being sufficient, in ordinary
instances, to expel it shortly after the delivery of the shoulders.
But, if the feet be imprudently brought down by an unskillful
accoucheur, the smaller bulk offered to the soft tissues of the
maternal generative parts, will not so completely dilate and adapt
them to the easy passage of the head, which in consequence, may
be so long delayed in its expulsion as to occasion the death of the
child.

Neither is it proper to employ any extracting force, for the pur-
pose of facilitating delivery, as the child may be destroyed by a
severe and injurious extension of the neck ; it being borne in mind
that the neck of the child before birth is capable of sustaining no
more extractive force than afterward, and any great amount of
traction must injure the spinal marrow; beside, the arms not being
maintained in their position by the contractions of the uterus,
become arrested, and do not simultateously participate in the
descent accomplished artificially by traction; hence, as the head

414

AMERICAN ECLECTIC OBSTETRICS.

advances, they become placed on its sides, and greatly interfere
with its expulsion during the last period of the labor. When the
contractions of the uterus expel the child, the arras are born
in the position originally assumed by them ; but if traction be
made, its influence is exerted only on the body, and there is inva-
riably a tendency of the arms to rise along the sides of the head,
because the pressure of the uterine fundus is then no longer
exerted upon them to keep them in place. Consequently, it is bad
practice in ordinary cases, to bring down the feet, as well as to
attempt to hasten labor by making artificial traction.

In these preternatural cases, the physician should be more atten-
tive to the progress of labor than in natural cases, being careful,
however, not to alarm his patient by an unnecessary display of
over-anxiety, or officiousness, nor to make any injudicious attempts
to advance its progress during the early stage. During the escape
of the breech from the vulva, the perineum becomes greatly dis-
tended, and it should be steadily supported in order to prevent the
too rapid advance of the pelvic extremity, as well as to impart
a motion to it in the direction of the inferior part of the pelvic
axis, and without which movement much delay would be occa-
sioned. Dr. Collins remarks : " The most critical part of the
delivery, should much delay take place, is during the passage of
the head, which pressing continuously on the funis speedily
deprives the child of life. To guard against this, therefore, the
breech should be permitted to pass slowly and unassisted, so as
gradually and perfectly to dilate the soft parts, thereby greatly
facilitating the completion of the labor." When the contractions
of the uterus are sufficient to expel the fetus, however slowly, no
interference whatever is required ; it is only when the breech has
so far advanced externally as to permit the cord to be reached,
that any aid will be needed. The cord must be drawn down a lit-
tle, in order to prevent it from being broken off, as well as to pre-
vent its vessels from being stretched. The umbilical arteries of
the cord run in a tortuous manner around the vein, and conse-
quently, any stretching of the cord would, by diminishing their
caliber, as effectually check the circulation, as from direct pressure
of the head while in the pelvis ; hence, by keeping a loop of the
funis slack, we prevent any danger to the child from tension of the
cord during the advance of the body. After the cord has been
paced within reach, the necessity for interference can always be
determined by the character of its pulsations ; if these be strong,

PRETERNATURAL LABOR — PELVIC PRESENTATIONS. 415

haste is not required ; if they become feeble, irregular, or intermit-
tent, assistance must not be delayed, and the body of the child may
be brought down during a pain ; if they have ceased, an indication
of the child's death, the case should be left to nature. A soft nap-
kin should always be wrapped around the child's body, as soon as
the feet have been delivered, which will protect its surface from
being injured, as well as enable the physician to hold it more
firmly when performing any manipulation which may be required.

The passage of the shoulders through the external parts must
be carefully attended to, and if they do not present favorably at
the outlet, rotation should be made, to bring the proper one under
the pubic arch, and the other into the cavity of the sacrum. If
the arms remain by the side of the child, there will be no delay in
the expulsion of the shoulder, but if they have oecome elevated,
the advance of the shoulders and head will be very much, if not
entirely, retarded. To obviate this, one or two fingers are to be
passed along the arm, as near as possible to the elbow, when the
elbow must be drawn downward and forward, across the face and
chest, until it arrives at the outlet; one arm baving been liberated,
the other may be drawn down with but little difficulty. The
easiest way of effecting the descent of the arms, is to begin with
the one nearest to the perineum, and to draw downward, and
anteriorly over the face and chest of the child; if the force be
directly downward, or toward the back of the child, or be made
with suddenness or violence, the arm may be broken or dislocated,
and the soft parts of the mother be considerably injured. The
blunt hook has been advised in these cases, but I see no necessity
for it, as the arms may always be reached by the fingers.

The shoulders and arms having escaped, the situation of the
head must be ascertained by an examination. During the progress
of the labor the accoucheur must so manage, if required, that
when the head is in the pelvis, the face will be directed toward the
hollow of the sacrum. This being the case, he will elevate the
child's body toward the maternal abdomen, so as to bring the long
diameter (mento-occipital) of its head in correspondence with the
axis of the inferior strait; and should the chin have departed
from the breast, he will introduce two fingers and place them upon
the child's upper jaw, and by gentle pressure depress the chin upon
the breast, thus facilitating the expulsion of the head by present-
ing a shorter diameter of the head to the inferior strait. At this
time, the head, being freed from the uterus, is not influenced by its

416

AMERICAN ECLECTIC OBSTETRICS.

contractions, and the auxiliary aid of the abdominal muscles will
be required to terminate the delivery; consequently, instead of
waiting for a pain, the patient should be urged to bear down, that
the head may be expelled, for any delay will endanger the life of
the child, from the continued pressure of the head upon the cord.
Assistance may likewise be given, by applying extractive force to
the shoulders in the direction of the axis of the inferior strait,
bearing in mind, however, that an excessive amount of such force,
will seriously injure the child's neck. Should a delay in the pas-
sage of the head occur, the child may be frequently saved, by
introducing a finger into its mouth to remove any mucus which
may be there, and then " pass two fingers upward until they reach
the two maxillary bones, and cover the nose; by doing this, the
backs of the fingers, pressing the perineum backward, serve to
keep an open communication with the air, and the child can
breathe very well until the expulsive efforts come on." (Meigs.)
This author also recommends the forceps to be within reach in all
pelvic presentations, feeling well assured that he has saved several
lives which would have been lost but for this precaution ; I am
satisfied that this course is not only wise and prudent, but that
a resort to the forceps in all cases of delay in the delivery of the
head, will result in benefit to both the child and mother. If, how-
ever, the child be dead, as known by the cessation of pulsation iu
the cord, and the head be very large, or some obstacle presents
rendering it very difficult to extract with the forceps, the perfora-
tor may be introduced behind one or both ears, for the purpose of
lessening the size of the head, and thus terminating the labor.
The head being born, the rest of the labor will be managed as in
natural labors.

When the uterine contractions become inefficient, previous to
the expulsion of the breech, or when, from any cause, a quick
delivery is demanded, one or two fingers may be passed up and
hooked into the groin, and steady and gentle traction be made during
the presence of a pain ; the pains may, likewise, be rendered more
efficient by the administration of four or five grains of Caulophyl-
lin, which may be repeated every half hour, until the uterine con-
tractions are sufficiently powerful. Sometimes a combination of
Caulophyllin and Cimicifugin may be administered, but on no
account is Ergot to be given in a case of pelvic presentation. For
the purpose of extracting the breech, the fillet and blunt hook have
been recommended — these may sometimes be useful, but great care

PRETERNATURAL LABOR — PELVIC PRESENTATIONS. 417

is required in using them, lest the thighs of the child be fractured.
And it must never be lost sight of, that whenever extracting force
is employed, it should always be made in the direction of the axis
of the pelvic cavity, according to the part at which resistance is
offered.

The most difficult cases of breech deliveries are those in which
the sacrum of the child is directed toward the maternal sacrum, and
rotation has not been effected ; in consequence, when the head
reaches the inferior strait, the face of the child will be to the pubis,
and its occiput to the sacrum. This will occasion considerable diffi-
cult}T in the delivery of the head, beside being a very dangerous
situation for the child. A complete rotation of the child's body, so
as to reverse the positions, and bring the face eventually to the hol-
low of the sacrum, must be produced, either spontaneously, or by
the management of the accoucheur. In these sacro-sacral positions,
when the breech is low in the pelvis, and not yet delivered, and
rotation has not taken place, two or three fingers may be introduced
for the purpose of forcing, by steady and continuous pressure, that
hip which i3 situated the most anteriorly, toward the pubic sym-
physis; and the delivery of the hips being achieved in this position,
they may be enveloped in a soft napkin, and as the pains expel the
body, the accoucheur will gradually continue the rotation in such a
manner, that the face will be in the desired position at the time it
reaches the lower part of the pelvic cavity. And in effecting this
change, should the pains urge the body too rapidly onward, he
must, by counter-pressure, prevent its too hasty exit, until the rota-
tion is satisfactorily accomplished.

Sometimes the body of the child will be held by the womb so
forcibly, during a pain, that the rotation can not be performed ; the
practitioner should then operate during the absence of pain, first
pushing the child's body upward as far as possible, and then giving
to it a compound movement, by drawing it downward and at the
same time rotating it.

Should the head, however, have reached the inferior strait with
the face to the pubis, the practitioner will cause the female to lie on
her back, her hips being brought over the edge of the bed, and the
feet supported on chairs by two assistants. As soon as the shoulders
are delivered, an assistant will carry the body of the child back-
ward, while the accoucheur will press the perineum back, with one
hand, to prevent its forcing the throat against the pubis, and with
the other he will bring down the chin, either by introducing two

418

AMERICAN ECLECTIC OBSTETRICS.

fingers into the mouth, or by placing them upon the upper jaw.
The chin having been thus depressed, the woman must be urged to
bear down forcibly, in order to facilitate the expulsion of the head.
Should this method fail, the forceps will probably be required, or
perhaps the perforator.

I have stated heretofore, that it is bad practice, in breech presenta-
tions, to bring down the feet; still, there maybe instances where
this will be demanded, and where it will become necessary, also to
employ some forcible traction, in order to expedite delivery. Thus,
in cases where the breech is large and the pelvis narrow, it may be
almost impossible for delivery to be effected, without some inter-
ference of this kind; accidents may also occur, at the commencement
of labor, which, by jeopardizing the life of the mother, require a
hastening of the labor, as in convulsions, hemorrhage, etc. But
should these occur while the os uteri is undilated, temporizing and
palliative measures only can be employed, and no attempts what-
ever should be made to introduce the hand within the uterus for the
purpose of bringing down the feet.

Should these accidents occur when the breech is low in the pel-
vis but still within the uterus, we must be guided by the circumstances.
If the os uteri be rigid, no attempts to introduce the hand must be
made until the rigidity is overcome : if it be dilatable and in
proper condition, the hand may be introduced, whether the mem-
branes be ruptured or not, and the feet brought down.

If interference is demanded after the breech has been expelled from
the uterus, the feet must not be brought down, unless the pelvis be
large, or the breech be small, and unless the pains have ceased to be
efficient. In this case, if the breech be very low in the pelvis, a
finger may be passed above one or both groins, and during the
presence of pain, traction may be made in the direction of the
pelvic axis. If the breech can not be delivered by this means, the
fillet may be employed, and if this can not be applied, the blunt
hook must be resorted to.

As remarked in a previous chapter (see page 305), knee and feet
presentations are mere deviations from the breech, the labors being
more painful and difficult, with greater risk to the child, but requir-
ing a similar management. "When the knee presents, it may be
mistaken for an elbow ; but may be distinguished from it by the
rounded patella with its flat surface, and which is more or less
movable on the condyles of the thigh bone : the olecranon of the
elbow is pointed and sharp — not flat, like the patella, and is not

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 419

movable. Naegele observes that the " knee is thicker, has two
prominences, and a depression between them, while the elbow is
thinner, and presents to the feel, between the two prominences, a
projection in which it seems to end."

In knee presentations it is always advisable to convert them into
footling cases, which may be effected by pushing the fetus upward
during the absence of pain, so that sufficient space may be gained
to bring down the feet.

A foot may be determined from a hand, by its rounded instep,
its prominent heel, the toes being all in one line, and no one of the
digits being an opponent to the others: the hand has no rounded
instep, no prominent heel, the digits are not all in one line, there is
a flattened palm, the fingers longer than the toes, not all of the
same length, and the thumb opposed to the fingers. The foot is
also longer than the hand, and its sole flatter, and the presence of
the heel, with the anklebone on each side, will distinguish it from
the hand and wrist.

In cases of breech presentation, various means should be in
readiness, as a warm bath, etc., to resuscitate the child, should ani-
mation be suspended ; its limbs and genitals should also be carefully
examined before leaving it; and if they present appearances of
injury, a fomentation of the flowers of St. John-wort may be
applied, or some evaporating lotion.

Rigidity of the os-uteri, pelvic tumors or deformities, and other
circumstances which may also be present in vertex presentations,
occasioning difficult labor, must be treated as directed under the
head of difficult labor.

CHAPTER XXXIII.

OF PRETERNATURAL LABOR. — SHOULDER PRESENTATIONS.

It is as difficult to assign a sufficient explanation of the cause of
presentations of the superior extremities, as those of the pelvic.
They have been attributed to irregular distension of the uterus, to
uterine obliquity, to irregular contractions at an early period of
labor, etc., and they may have existed primarily. Dr. Rigby
remarks : " We may, therefore, state that the causes of arm or
shoulder presentation are of two kinds, viz.: when the uterus has

420 AMERICAN ECLECTIC OBSTETRICS.

been distended by an unusal quantity of liquor amnii, or when,
from a faulty condition of the early pains of labor, its form has
been altered, and with it the position of the child." Still, these
" cross-births,*' as they are often called, are involved in much
obscurity; there appears to be a natural tendency to them with
some women, who have them at every labor.

Previous to the commencement of labor, there are no positive
signs by which we can determine a presentation of a shoulder, or
of any part of the body ; and no dependence can be placed in an
unusual figure of the uterus, as ascertained by applying the hand
over the abdomen. A transverse presentation of the fetus may be
suspected when the os uteri dilates slowly, when the membranes
protrude into the vagina in an elongated form, when the presenting
part is beyond the reach of the finger, and when, after the rupture
of the membranes, the pains cease for several hours. A vaginal
examination will determine the correctness of our suspicions, as
well as inform us of the position ; and both of these points should
be satisfactorily ascertained before any interference is attempted by
the practitioner.

I have already remarked, on page 304, that there are two posi-
tions for each shoulder, viz.: FIRST LEFT CEPHALO-ILIAC,
and FIRST RIGHT CEPHALO-ILIAC of the RIGHT SHOUL-
DER, and SECOND LEFT CEPHALO-ILIAC, and SECOND
RIGHT CEPHALO-ILIAC of the LEFT SHOULDER ; and to
which the reader is referred for an explanation of the situation of
the child in these several positions.

DIAGNOSIS. — Previous to the rupture of the membranes, the
presenting part is commonly elevated beyond the reach of the
practitioner's finger, but it may always be felt after they have
given way ; and then a careful examination should be made, that
no doubts may exist with regard to the nature of the case. This
should be satisfactorily accomplished, in all instances, immediately
after the membranes have ruptured, and if necessary, a part of the
hand, or even the whole of it, should be introduced into the
vagina, for the purpose of making a correct diagnosis. Should
the presenting part be an elbow or hand, it may be felt offering at
the mouth of the uterus before the rupture of the membranes ; and
sometimes, after a hand has been clearly detected at the os uteri,
it has subsequently become withdrawn, and the vertex found pre-
senting. The shoulder may be known from the head, by its being
less bulky, less firm and resisting, and by the absence of sutures

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 421

and fontanelles ; from the breech, by the absence of the anus and
parts of generation, and by being not so large and less fleshy.
The finger, on coming in contact with it, first, detects the project-
ing acromion, in front of which will be felt the clavicle, below
which the ribs and intercostal spaces will be readily made oat ;
then carrying the finger behind the acromial process, the spinous
process of the scapula will be detected, the surface inferior to it
will be found plane and smooth, terminating below in the acute
inferior angle of the scapula, which is movable and will permit the
finger to pass under it. The arm may also be felt and distinguished
from the thigh by its size, and sometimes the depression in the
neck can be recognized.

Having ascertained the case to be a shoulder presentation, the
next and most important point is to determine which shoulder
presents, and its position. If this can not be ascertained at an
early stage of the labor, it always can in time to be remedied, and
that is, when the dilatation will admit; this may be effected by
ascertaining where the fetal head lies, and the situation of its back.
The side to which the head is directed may be known by the axilla,
which must always look in an opposite direction to that of the
head ; thus, if the axillary space looks toward the left ilium of the
mother, the fetal head will be to her right ilium, and vice versa.
The direction of the back may be known by the scapula and ver-
tebrae behind, and the clavicle, ribs, and intercostal spaces before.
Should there be the least doubt relative to these points, the practi-
tioner should not hesitate to bring down an arm in order to assist
him in his diagnosis, as it will occasion no difficulty in the opera-
tion of turning; but in effecting it, great care should be taken not
to make the slightest traction upon the fetus.

When the elbow presents, it may be recognized by three bony
prominences, viz.: the olecranon and the two condyles, and by the
bend of the elbow occasioned by the flexion of the fore-arm upon
the arm. The position of the fetal head may also be known
readily, being always toward the side opposite to that in which the
elbow is directed ; and the fore-arm usually rests upon the ante-
rior of the child's body, as just remarked above. I repeat, should
there be the least doubt as to the position, or the presentation, and
provided the membranes have ruptured, the arm may be carefully
brought down, making no traction whatever, upon the fetus. To
distinguish a knee from an elbow has already been explained on
page 418-19.

422

AMERICAN ECLECTIC OBSTETRICS.

Sometimes a hand will hang down in the vagina, or even out at
the vulva, and be mistaken for a foot. (See page 419.) If the
young accoucheur will accustom himself to feel and handle the
various parts of a newly-born child, as the feet, knees, hands,
elbow, shoulders, etc., he will acquire a ready tact in diagnosticat-
ing, which will prove greatly advantageous. We may learn which
shoulder presents, by the hand. If the palmar surface be found
directed toward the pubic symphysis, the thumb turning to the
right side of the maternal pelvis, it is the right hand, and conse-
quently a presentation of the right shoulder; if the thumb turn to
the left side, it is the left hand, and left shoulder presentation. If
the dorsal surface or back of the hand be directed in front, the
thumb being toward the right side of the pelvis, it indicates the
presence of the left hand and shoulder; if the thumb be toward
the left side, it is the right hand and shoulder presenting. The
head is always in the direction of the thumb; thus, if the thumb
be toward the left side, the head will be in the left-iliac fossa, and
vice versa; if the palmar surface of the hand be in front, the
child's face will be looking toward its mother's abdomen ; if the
dorsal surface be in front, the back of the child will be toward the
maternal abdomen.

Having ascertained that the presentation is of the shoulder, the
practitioner should immediately inform the husband or friends
that it is a " cross birth," and explain to them, without any reserve,
the necessity for interference, and the hazards to the child as well
as to the mother. Whenever it is possible, council should be had,
that the friends may be thoroughly satisfied, and also that no sub-
sequent censure may be attached to the attendant, should serious
consequences result. The patient should, likewise, be informed
that labor can not proceed without artificial aid, and the reason
made known to her; and this should be done in a kind and gentle
manner, carefully avoiding any discouraging word, look, or action
But this communication should not be made to her, until we are
about to commence attempting the version.

TREATMENT OF SHOULDER PRESENTATIONS.

When a shoulder presentation is suspected or ascertained pre-
vious to the rupture of the membranes, and before the os uteri is
sufficiently dilated, every means should be used to preserve the
membranes entire ; examinations should be made with care, and
the female should be kept in a horizontal position. No attempts

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS.

423

whatever should be made to force the hand into the uterios until
it is dilated or dilatable, and even then, not until the position is
satisfactorily determined. In the meantime, the rectum should be
evacuated by the administration of a mild, emollient enema, if
necessary, and the bladder by a catheter; for the operation of
turning, which is the one usually recommended and pursued in
these cases, should never be undertaken until these evacuations
have been effected either naturally or artificially.

As soon as the os uteri has become dilated to the size of half a
dollar, it being also, together with the vagina and soft parts, per-
fectly soft and yielding, the membranes remaining entire, the prac-
titioner may carefully proceed to effect the operation of turning
the child. This is, in fact, the most favorable period for the opera-
tion, as the presence of the amniotic fluid within the cavity of
the uterus not only admits a ready introduction of the hand, but,
by floating the child, permits it to be turned in any direction.
The practitioner can not be too careful as to the time when he
enters a hand into the uterine cavity : if he makes the attempt at
too early a period, the most lamentable results will follow; if it
be too long delayed, the hazards and difficulties are increased, and
the patient suffers uselessly.

The position and presentation having been ascertained, the os
uteri dilated, sott and yielding, with no rigidity of the soft parts,
and the practitioner having waited for a period consistent with the
integrity of the membranes and the preservation of the liquor
aninii, it would be unwise to wait until the complete dilatation of
the os uteri. The rectum and bladder of the patient having been
previously evacuated, she must be placed on her back, across the
bed, which is by far the most desirable position, with her hips
brought a little over its edge, her feet resting on two high stools,
or properly supported by assistants, so as to flex the limbs well,
and thus favor a relaxation of the abdominal muscles. She should
by no means be exposed, but should be covered by some bed-
clothing, suitable to the temperature of the season, and, for the
purpose of receiving discharges, a thick layer of cloths should be
placed oti the floor, immediately beneath her.

The practitioner will now remove his coat, bare his arm to the
elbow, and jmoint it well with sweet oil, or lard; the vagina
should also be similarly anointed. To protect himself from the
discharges, a sheet or apron may be worn over his dress. Every-
thing thus prepared, he will take his seat, at a convenient distance

424

AMERICAN ECLECTIC OBSTETRICS.

for operating, between the patient's limbs; and throughout the
whole operation, he should be cool and deliberate, manifesting no
haste, excitement, trepidation, nor hesitation.

There is some choice of the hand to be introduced — that one
should always be used which can the most conveniently effect the
version ; and the common rule is, to use the hand whose palmar
surface would, when opened within /he uterine cavity, be directed
to the anterior surface of the child's body. Should the child's
hand present, this may readily be ascertained by grasping it as in
shaking hands, and that hand should be used, the palm of which
comes in contact with the fetal palm.

It is not unfrequently the case, that the contractions of the
uterus so completely benumb the hand -which has been first intro-
duced, that the accoucheur being unable to use it, is compelled to
withdraw it, and employ the other. Dr. Lee advises us, in all
cases, no matter what the situation of the trunk and extremities,
to pass the hand up between the anterior and shallow part of the
pelvis, and the presenting part of the child.

The proper period for passing the hand within the vagina, is
during a pain ; the fingers may be held together, in a conical form
and thus slowly introduced, or, two fingers, then three, four, and
lastly the thumb strongly flexed into the palm, may be passed
within the vulva; while passing the vaginal sphincter considerable
pain will be produced, but this will be materially, if not entirely,
lessened, after the hand has entered the vagina. The hand may
now rest stationary for a short time, to produce toleration <ff its
presence, as well as to dilate the parts. Its introduction within the
uterine cavity, must be during the absence of pain ; an attempt to
pass it within the womb, during a pain, would probably rupture
the membranes, and allow the amniotic fluid to escape before the
vagina was sufficiently plugged up by the arm to prevent it. The
fingers are to be passed within the os uteri in a conical form, and
carefully and gently pushed upward until the hand is fully within
the uterine cavity. If the presence of the hand has not excited
uterine contractions, followed by rupture of the membranes, the
bag of waters should rest on the hand, and be passed up as far as
possible before rupturing them; the presenting part should also be
pushed upward and to the left or right, according as the head
may be on the left or right side of the uterus. (Fig. 60.)
While the hand is entering the os uteri, the uterus should be kept .
steady by the other hand of the operator, or what is much better,

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 42")

an assistant should place his hand on Fig. 60.

the abdomen, over the fundus of the
womb, to steady the organ, and at the
same time to maintain a gentle pres-
sure downward, to keep the os uteri
within the strait. Usually, the mem-
branes give way as the hand is passing
within the uterine cavity, even before
the feet are reached, in which case
the hand and arm must be pressed
firmly forward to plug up the orifice,
lest the amniotic fluid escapes, there-
by causing the version to be more
difficult.

Should a pain come on during the
entrance of the hand into the uterus, it
must be kept perfectly still, and when
within the cavity of the womb, it
should be opened and made to cover
the body of the child whenever uterine contractions come on ; for
any attempts at moving, or resisting the action of the organ at this
time, might occasion its rupture. The membranes having been rup-
tured, the hand enters into the cavity of the ovum, along the anterior
surface of the child, and should be passed up to the umbilicus where
the funis will be felt, and in the neighborhood of which a foot will
generally be found. Having reached a foot, secure it between
two fingers, and search for the other ; and if the contractions come
on, the hand must be opened, and clasped over the child's body.
If, after a reasonable time, the other foot can not be found, the ver-'v
sion may be accomplished by the one foot, being certain, however,
that it is a foot, before attempting the change. Frequently, the
contractions of the uterus are so severe that the hand of the oper-
ator becomes cramped, numbed, or extremely painful, and its nicer
tact of feeling becomes so impaired, that, without the greatest
care, he may confound a hand with a foot. On this point be
exceedingly cautious. "VVe are advised by Dr. Radford, of Man-
chester, Eng., who has had much experience in difficult cases of
obstetrics, " never to bring down more than one foot in the manual
operation of turning ; because the other thigh, being flexed upon
the abdomen, offers a larger circumference than if it were extracted,
and thus prepares the passages for the more easy transit of the
28

426

AMERICAN ECLECTIC OBSTETRICS.

shoulders and head. The advantage of this practice consists in its
affording greater safety to the child; the disadvantage, in its cre-
ating more difficulty in accomplishing the evolution." (Ramsbot-
ham.) Prof. Meigs, who is the highest obstetric authority in this
country, observes in his Obstetrics : "at length, after more or less
research, one or both feet, or a knee is found ; and whether it be
one or the other, it should be taken hold of; for it is nearly a
matter of indifference whether it be one foot or both, or one knee
that is used as the point on which to act in turning the child. Dr.
Collins, p. 69, remarks, on this point, that 'it is quite sufficient to
bring down one foot,' and I find that Dr. Simpson of Edinburgh,
is of the same opinion — deeming it far more injurious to make per-
verse attempts at exploration, than to deliver by one foot only. I
say, nearly a matter of indifference, because, the object being to
turn the child as soon as practicable, with proper caution it may be
effected in either of these ways ; it is always desirable to get the hand
out of the uterus as soon as may be, and it is far better to turn by one
foot or by a knee, than to incur the risk of laceration or contu-
sions of the organ, by a tedious search after the foot, which, if it
be not originally near its fellow, is very hard to be found by any
search for it. The inexperienced student can have little notion of
the extreme difficulty there is to move the hand about while it is
compressed betwixt the womb and the child ; a short experiment
of this difficulty would suffice to convince him of the propriety of
the foregoing directions. If he should use the knee as a point of
traction, it would be very easy, when the version is nearly com-
plete, to draw the foot down. If he use only one foot to turn by,
he will have nearly all the proposed advantage of the breech pre-
sentation, combined with the greater facility enjoyed in manipulat-
ing in the footling case — that is to say, he will have the abundant
dilitation, and the power of traction of the limb. It sometimes
happens, that a foot is met with close to the orifice; so that, even
without carrying the hand within the uterus, the foot can be
hooked down by means of one or two fingers, as has been done by
Dr. Robert Lee, of London." It will thus be perceived, that the
most eminent accoucheurs of this country and Great Britain, are
opposed to any lengthy search after both feet, in cases of turning,
and my own experience is in favor of performing version by one
foot, when there is any considerable delay or difficulty in securing
both.

If it be possible to select a foot, we should take that which is

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 427

opposite to the presenting hand or elbow, and which will be situated
more toward the anterior part of the pelvis. The period for effect-
ing the version, is during the absence of pain, and any attempts to
turn during a pain will not only be found nugatory, but may be
productive of serious consequences.
While the pains are off, the uterus
will be found soft and yielding, and
the operation may be effected with less
danger; the version should be made
over the anterior and not the posterior
surface of the child, holding the limb
or limbs firmly, and slowly and gently
drawing them down into the vagina,
and, if possible, to the external ori-
fice. {Fig. 61.) Should the uterus
contract, the operator must cease his
efforts, and if the pain be severe, it
may be necessary for him to straighten
out the hand and let the foot go,
recovering it after the pain has sub-
sided. He should place his unoccu-
pied hand externally on the patient's
abdomen, and aid in accomplishing
the version by pushing the child's
breech downward, while he is making traction with the other hand.
As the arm is gradually withdrawn, the amniotic fluid will gush
out, and soil the dress of the operator, if he has not previously
protected it*by a covering.

The version having been completed, the patient may be carefully
placed in bed, leaving the rest of the labor to the natural efforts,
and managing it as directed in breech and feet presentations, page
413, being particular to have the child's face in the hollow of the
sacrum when the head arrives at the lower strait. Some obstetri-
cians recommend to terminate the delivery by a continuation of
artificial efforts, gently and cautiously extracting the body whenever
the pains are on ; but I consider this as meddlesome and very
improper ; no such attempt should be made, unless circumstances
are present demanding them. After the delivery of the placenta,
the female should be properly bandaged, put to bed, and a soothing
preparation administered, as eight or ten grains of the compound
powder of Ipecacuanha and Opium, combined with three or four

428

AMERICAN ECLECTIC OBSTETRICS.

grains of Capsicum — the addition of the Capsicum, while it does
not interfere with the soothing influence of this powder, tends to
lessen any disposition to hemorrhage which may be present : or
twenty or thirty drops of Laudanum may be exhibited ; or a solu-
tion of Morphia in proper quantity ; she should also be kept quiet
and free from noise and company, and if possible, take a short
sleep. Some gruel may be allowed, if requested.

The operation of turning, no matter how skillfully performed, is
always a dangerous one for the mother, and should be performed
with the greatest care and gentleness; any hasty or careless push-
ing, any thrusting of the knuckles in opposition to the contracted
womb, any attempts at version during a pain, may occasion lacera-
tion of the vagina, rupture of the uterus, or, perhaps, both of these
may occur. " If, under your attempts to turn, you feel any fibers
giving Avay, whether in the womb or vagina, withdraw the hand
immediately." — (Blundell.)

Unfortunately, however, preternatural presentations do not always
present the same features. It is frequently the case that the mem-
branes will have prematurely ruptured, and the os uteri will not be
sufficiently dilated; or, when fully dilated, there may be violent
pains, with rigidity and irritation of the parts. In these instances
no attempts whatever must be made to force the hand within the
uterus, as they will only tend to increase the difficulty. Dilatation
must be aided by the internal use of tincture of Gelseminum, in
two or four-drachm doses, the compound tincture of Lobelia aud
Capsicum, or a combination of these, three parts of the former to
one of the latter; vaginal emollient injections with or without
Laudanum, according to the nature of the case, may likewise be
exhibited, and in some instances the warm bath, or warm hip-bath,
will be found very beneficial. I have found fomentations to the
vulva, of Hops and Lobelia combined, very useful to aid in the
relaxation of the parts. Chloroform has been advised in these
instances, or Ether, inhaled to produce complete anaesthesia, and this
will undoubtedly, be found of advantage, by removing the volun-
tary efforts of the mother, especially the actions of the diaphragm
and abdominal muscles — though it must be recollected, that the
most profound anaesthesia does not completely check the contractions
of the uterus.

Bleeding, ad deliquum animi, is the practice most commonly
advised in these cases, and there is no doubt but that it will gener-
ally produce the desired relaxation, but I am decidedly opposed to

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 429

it, because its after effects upon the patient are frequently irremedi-
able; it induces a debility of the nervous and vascular systems,
which, if ever positively recovered from, will require months and
even years of proper treatment to accomplish ; it occasionally fails
to effect the desired relaxation ; and should hemorrhage, or other
symptoms come on after venesection, there may not remain sufficient
energy or vitality in the system to successfully oppose a fatal result.
On the other hand, the desired relaxation can always be effected by
the tincture of Gelseminum, or its combination with the Lobelia
and Capsicum tincture, by which all rigidity will be overcome, the
pulse will be lessened, abnormal heat and tenderness of the parts
alleviated, and no strength of the patient actually lost, and should
symptoms occur requiring an opposing force of the system, the
patient may readily and permanently be restored to her usual vigor,
by the employment of stimulants.

No haste is required in these cases — viz. : when the os is not
dilated, with premature rupture of the membranes, or, when it is
fully dilated, the waters having been discharged, and the pains
violent — the safety of the mother is the grand object, and patience
is required on the part of the practitioner, together with cool,
calm, and deliberate action. As soon as the parts are in proper
condition, the hand may be introduced, and version effected as
before explained. In these cases, where the waters have been dis-
charged, it is better to turn by a knee, than allow the hand to
remain too long within the uterus searching for a foot. When the
pains are very violent, and the uterus contracts firmly about the
body of the child, the tincture of Gelseminum should be given,
combined with a sufficient quantity of Laudanum, which will com-
monly arrest the powerful action of the organ, and at the same
time produce considerable relaxation of it, as well as of the soft
parts, so that the hand can be introduced; I have likewise found
that the tincture of Gelseminum three parts combined with the
tincture of Aconite root one part, and administered in doses of ten
or twenty drops, every half hour or hour as the case may require,
will overcome the powerful contractions of the uterus, lessen the
pains materially, and render the organ more yielding; and it is
more especially in these instances where a resort to anaesthetics
is advised. Of course, in these cases, the hazard to the child is
always much greater. Sometimes, although the foot descends into
the vaginal cavity, yet the shoulder being wedged in the pelvic
brim does not recede, and the more forcible the traction is upon

430

AMERICAN ECLECTIC OBSTETRICS.

the foot, the more firmly does the shoulder become fixed in the
brim, while the breech will not pass down. In these cases, a noose
of strong tape or ribbon must be fixed round the ankle of the foot
in the vagina, upon which traction may be made with one hand,
in the direction of the pelvic axis, while the other, with the ends
of the fingers placed against the ribs or axilla, must make at the
same time, a steady, upward pressure, by means of which, the
shoulder will be dislodged, affording by its recession, a space for
the descent of the breech. The rest of the delivery is then termi-
nated as in the before-named instances.

In cases of shoulder presentation where the arm has descended,
it should never be returned within the uterine cavity, unless in
attempting cephalic version, as referred to hereafter. The presence
of the arm, assists the practitioner in forming his diagnosis as to
position, etc., and never interferes with the introduction of the
hand for the operation of turning. A piece of ribbon may, how-
ever, be attached to the wrist for the purpose of preventing the
arm from rising alongside of the head after the version is accom-
plished, and thus avoiding any difficulty in its delivery. Any
pulling or twisting of the arm is highly censurable ; pulling at the
arm will not assist the least in the delivery of the child, and twist-
ing or amputating it has been performed on several occasions, in
which the children were subsequently born alive, and some of
whom lived to advanced age, in this mutilated condition. Should
any cause be present demanding the removal of the prolapsed arm,
it should always be made known to the relatives together with the
reasons, previous to any attempt at the mutilation.

It will sometimes be the case, that notwithstanding our treat-
ment, the contractions of the uterus will continue powerful and
almost unremitting, obstinately resisting the slightest attempts to
introduce the hand ; in such instances, the only method is to wait,
in the hope that spontaneous evolution may expel the fetus ; but
if it be dead, as known by auscultation, or if symptoms of sinking
or exhaustion appear, we should proceed at once to remove the
child by exvisceration. In these instances, the child will generally
be dead before interference will be required, and the grand object
of the practitioner, must always be, to save the mother's life, if
possible. In many instances the mixture of the tinctures of Gel-
seminum and Aconite root, previously referred to, will be found
very successful in overcoming this excitable condition of the uterus.
And when the stomach is also irritable, rejecting almost everything

PRETERNATURAL LABOR SHOULDER PRESENTATIONS. 431

exhibited, a combination of the tinctures of Gelseminum and
Opium, or Morphia, will frequently prove useful.

SPONTANEOUS EVOLUTION, is an idea, which was ad-
vanced by Denman in 1772, who noticed that the labor, in shoulder
presentations, where the liquor amnii had long been discharged,
occasionally terminated by the natural efforts, the breech being
expelled first, and who, consequently supposed, that the efforts of
the uterus gradually turned the child so as to cause the shoulders
to rise as the breech descended. In 1811, Dr. Douglas, of Dublin,
showed that this view was not correct, but that the fetus instead
of being turned was actually expelled doubled up. His description
of the occurrence, which he has more correctly named "sponta-
neous expulsion," is, according to Ramsbotham, as follows: "By
the continuance of the powerful uterine contractions, the whole of
the arm is protruded externally, the shoulder and chest being pro-
pelled low into the pelvic cavity. The acromion then appears
under the symphysis pubis ; and as the loins and breech descend
into the pelvis on one side, the apex of the shoulder is directed
upward toward the mons veneris. Further room is thus gained
for the complete reception of the breech into the cavity of the
sacrum, and that part of the child's body is eventually expelled,
sweeping the sacrum, and distending the perineum to a vast
extent. As, during the whole of this process, the head remains
above the pelvic brim, it is evident that the apex of the shoulder
being external, the clavicle must be strongly pressed against the
under surface of the symphysis pubis; on which point, indeed, the
fetal body partially revolves, as on an axis; the other shoulder and
arm, and the head, being expelled last."

Spontaneous evolution, or spontaneous expulsion, seldom happens,
being more common in premature labors, and is always fatal to
the child, and exceedingly dangerous to the mother; the intense
and protracted sufferings which the mother undergoes are beyond
description, and no practitioner should ever trust to a delivery by
this method, unless under the circumstances heretofore named,
viz. : where every other resource fails. Beside, it is exceedingly
doubtful whether this spontaneous action will ensue at all, except
when the fetus is very small, or the pelvis much larger than ordi-
nary. Dr. Douglas says : " If the arm of the fetus should be
almost entirely protruded, with the shoulder pressing on the peri-
neum ; if a considerable portion of its thorax be in the hollow of

4S2

AMERICAN ECLECTIC OBSTETRICS.

the sacrum, with the axilla low in the pelvis ; if, with this disposi-
tion, the uterine efforts be still powerful, and if the thorax be
forced sensibly lower during the pressure of each successive pain,
the evolution may with great confidence be expected." A labor
in which spontaneous evolution is effected, requires unparalleled
voluntary efforts on the part'of the female, and is always accom-
panied with extreme bodily and mental suffering, frequently
occasioning death, either before, or soon after delivery; and should
the patieut survive, she is commonly left with some incurable
difficulty, which renders life anything but desirable. Velpeau
states that, in one hundred and thirty-seven labors of this descrip-
tion, only twelve children were born alive.

EXVISCERATTON, should be resorted to only as a last resource,
and should be employed in those cases where the membranes have
been ruptured for several hours, with no advance of the labor, and
also in instances where the child's body is firmly wedged at some
part of the pelvis, rendering the introduction of the hand impossi-
ble or extremely dangerous. In performing this operation there
is no necessity for amputating the arm, but an assistant will make
traction upon it, for the purpose of bringing as much of the child's
thorax into the pelvis as possible : the operator will then pass two
fingers of the left hand upward within the vagina, until he feels
one of the intercostal spaces, selecting a point as near the axilla as
he can ; the perforator is then to be passed along these two fingers,
and a free opening made with it in the selected intercostal space.
As it will be necessary to introduce the hand within this opening,
and into the cavity of the fetal thorax, for the purpose of remov-
ing its contents, the operator may divide one or more ribs, so that
the opening will be sufficiently large. After the removal of the
thoracic contents, the diaphragm may be perforated, and the liver
and intestines extracted. The removal of these organs will occa-
sion a collapse of the body, which will be expelled doubled up, if
the uterine contractions are sufficiently energetic, without any
further interference: but if the pains are weak and inefficient, or
have entirely ceased, the delivery must be artificially accomplished
by the crotchet, removing rib after rib, hips, buttocks, etc. ; or the
instrument may be " carried through the opening and fixed within
the fetal ilium ; the breech will soon be observed to descend, and
the case will be terminated as though nature had expelled the
child unaided."

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 433

Ramsbotham refers to an operation for decapitating the child, in
transverse presentations, when turning is impracticable, and when
the neck is directly over the brim : fortunately, I have never had
occasion to resort to it. He recommends the finger to be passed
around the neck, a large-sized blunt hook to be introduced upon
it, and the presenting part to be then brought as low into the pel-
vis as is consistent with the woman's safety. The hook must then
be steadied by an assistant, while the operator introduces the decap-
itator (a hook with an internal cutting edge) by the side of the
blunt hook : this latter is then removed, and the finger of the left
hand being kept constantly in contact with the blunt point of the
cutting hook, a sawing motion is communicatied to it by means of
the right hand, and the separation is thus effected ; after which
the child's body may be drawn out by the protruding arm, and the
head removed by a crotchet or blunt hook, introduced into the
mouth or the foramen magnum. These operations, of course, are
only to be performed when the child is dead, and which will almost
always be the case before a resort to them will be sanctioned by a
skillful accoucheur.

In cases of shoulder presentation, CEPHALIC VERSION" has
occasionally been attempted, in which the presenting part has
been pushed away and the head brought to the brim ; but the
operation has not received the sanction of many obstetricians, on
account of the difficulties attending it. Prof. Meigs, in his work
on Obstetrics, remarks: "It may be that those old practitioners of
the days of Queen Elizabeth may have sometimes succeeded, by
pushing up the presenting shoulder, in getting the head at last to
come to the strait again, but such an event appears to me in any
case most improbable." Prof. Miller observes : " Cephalic version
has but few advocates at the present day, and is confessedly appli-
cable to such a limited number of cases, that it is scarcely worthy
of our formal consideration."

It will thus be seen that authors generally agree in considering
cephalic version, at best, a doubtful expedient, and one to be
attempted only as a dernier resort in some particular instances ;
yet, notwithstanding the observations of the above gentlemen
concerning this operation, and the disrepute in which it is held}
Dr. M. B. Wright, a talented and skillful physician of Cin-
cinnati, Professor of Obstetrics in the Ohio Medical College, has
made known a method of cephalic version, which, I think, will

434

AMERICAN ECLECTIC OBSTETRICS.

become the more general practice in the management of shoulder
presentations as it becomes better known : since having perused
his essay, I have tried his method in two cases, and was highly
pleased at the successful results. I>r. "Wright's essay was on
" Difficult Labors and their Treatment," and was read before the
Ohio State Medical Society at one of their meetings, who awarded
a gold medal to him. In order that my readers may understand
his views, I will give his own language and quote freely from his
essay. After describing several cases treated successfully, he
remarks : —

"Now after all this, are we not justified in declaring —

" 1. That at an early period in labor, and especially if called
before the uterus has been deprived of its liquid contents, a shoul-
der may be converted into a vertex presentation more easily than
turning by the feet is ordinarily performed.

" 2. That although the membranes may have been long ruptured,
turning by the head can be accomplished with great facility.

" 3. That delivery by cephalic version may be speedily effected,
after repeated and ineffectual efforts have been made to turn by
the feet.

" 4. That cephalic version should receive a prominent, nay, lead-
ing place, as a means of expediting delivery in shoulder presenta-
tions.

" The second of the questions already proposed is, what mode of
proceeding will prove most favorable for the mother?

"In his chapter on podalic version, Churchill observes: 'On the
other hand, its disadvantages are not to be overlooked. From the
distance the head has to traverse, and the difficulty of seizing the
feet, and of turning the child in utero, there must ever be a fearful
risk of injury to the mother.'

" Upon an examination of the tabular views given by Lee, we
find that out of seventy-one cases of shoulder presentations, in
which turning by the feet was resorted to, 'seven women died
from rupture, and three from inflammation of the uterus!' Lacer-
ation and inflammation of the uterus are, therefore, the conse-
quences chiefly to be dreaded. Four of these cases of rupture
occurred in the practice of other accoucheurs, and three in patients
under my own care, and where no great difficulty was experienced
or force employed in turning.' * * *

" In cephalic version the hand does not enter the cavity of the
uterus, and, consequently, neither its walls, nor any portion of

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 435

them, are forcibly pushed out. The fetus is moved comparatively
little within the uterus, the head being already near the superior
strait ; while in podalic version the part to be first delivered is most
remote from the canal through which it must pass. In the former,
the injury to the mother can not result without great awkwardness
on the part of the obstetrician, while in the other we have reason
to feel surprised at the escape from injury. In turning by the feet,
the hand must necessarily be moved considerably within the
uterus, and often while it is contracting violently. In turning by
the head there is but little, if any, direct contact of the hand
within the uterus. In the one case, contusion of the uterus by the
hand is to be expected; in the other case there is no injury,
because there is no contact. Turning by the feet may occasion a
severe nervous shock: not so in changing the shoulder for the
head.

"How may the life of the child be best preserved? is the third
inquiry to be briefly answered.

"In describing the disadvantages of turning by the feet in all
cases, Churchill says: 'The mortality among the infants thus
brought into the world is very great. As far as our statistics
extend they yield 174 out of 518 delivered, or 1 in three.'

"The mortality in shoulder presentations is, doubtless, greater
than this. In the first place the position of the fetus weakens its
hold upon life. In the second place the hand is more difficult of
introduction into the uterus in shoulder than in head presentations,
and whatever force is required is sensibly felt by the fetus, and
upon that port of the body where pressure is made with the least
impunity.

"A timely resort to Cephalic version gives to the fetus almost as
much certainty of life as if the presentation had been originally of
the head. Why not? The maneuver amounts to but little more
than in rectification of deviated head positions.

"We are informed by Churchill, that 'Bush gave an account, in
1826, of fifteen cases, in which fourteen were born living. In 1827,
Ritgen collected forty-five successful cases. Riecke has had six-
teen cases.' In all the cases treated by myself from the beginning,
the children were born alive. The liability to compression of the
cord and consequent death of the fetus, is in proportion to the
length of the labor, or rather to the descent of the fetus in the
cavity of the pelvis. Hence, to be wholly successful, cephalic ver-

/

436

AMERICAN ECLECTIC OBSTETRICS.

sion should be performed a short time before, or soon after the
commencement of the second stage of labor.

"Can any one mode of treating shoulder presentations be relied
on exclusively ? The answer must be in the negative. We are
disposed to adopt the language of Cazeaux, 'that at the present
day it would be improper to embrace either opinon exclusive^, for
some cases are better suited to the cephalic version, while there
are others on the contrary, where the pelvic one is alone practi-
cable; consequently, both operations should be retained in prac-
tice, leaving the judgment of the accoucheur to determine the
cases, where the one or the other ought to be preferred.' And we
will conclude this part of the subject by stating a few of the cir-
cumstances under which the different modes of turning may be
adopted.

"Turning by the feet is to be preferred in cases of inefficient
uterine action, or in exhaustion from long continuance of labor;
in hemorrhage, convulsions, or in any case in which there may be
a demand for speedy delivery.

"Turning by the head should be selected in all cases where diffi-
culty arises from mal-position merely ; or in convulsions, hemor-
rhage, or prolapsus of the funis, if the uterus should be engaged
in vigorous expulsive efforts. In rupture of the uterus our
great reliance is in artificial delivery ; and the question nat-
urally suggested would be, which will guarantee the greatest
safety, podalic version, or cephalic version aided by the forceps?
And we would be guided in our action by the answer we gave to
the question.

•J> «V "j-* »A» vL# «X» »T» vL>

*T* *T* *T* "T* «T* Jf* <|>

" THE HAND TO BE USED. The relations of the fetus to
the pelvis having been ascertained, and the patient placed in a
proper position for the version, the next question is, which hand
shall be introduced into the vagina? "We answer, the hand,
the palm of which is directed naturally toward the breech of the
fetus. It will be seen at once, that if the fetus is to be moved
in the direction of the breech, and in correspondence with the
right side of the mother, and the left side of the operator, the
right hand could be used with most success. In cases in which
the head occupies the right iliac fossa, a choice could be given to
the left hand.

"THE PROLAPSED ARM. It is generally conceded, that in
turning by the feet, it is not necessary, nor would it be advauta-

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 437

geous, to return above the brim of the pelvis, the arm which may
have fallen, or been brought into, the vagina. In turning by the
head, on the contrary, its re-position admits of no doubt ; it is im-
perativel}7 demanded. It is not demanded in conseqence of any
difficulty in moving the shoulder by its presence, but in the adjust-
ment of the head at the superior strait, and its subsequent descent
through the pelvis. By bending the fore-arm of the fetus until
the hand is directed to the upper portion of the vagina, and then
pushing up the arm, the entire member will soon ascend above
the brim of the pelvis, and be no longer an obstacle to complete
version.

"The uterus undergoing gradual distention by the growth of
the fetus, and by increase in the quantity of liquor amnii, is not
from this cause alone excited to an expulsion of its contents. Let
a strong and sudden mechanical force be applied to the fibers of
the uterus, even to a limited extent, and contraction will speedily
follow. If any portion of the fetus should be pushed forcibly
against the fundus of the uterus, by attempts to rectify a mal-pre-
sentation, a more than corresponding resistance would soon apprise
us of a want of adroitness, and the probabilities of failure. The
hand of the manipulator in the vagina, imparts a sense of fullness,
and induces expulsive efforts on the part of the mother. Pressure
on the internal face of the perineum, or along the recto-vaginal
septum, urges the uterus to renewed or more energetic action.
Simple contact of the uterine and fetal surfaces in turning, does
not produce undue contraction of the uterine walls. The presence
of the hand, added to that of the fetus, within the uterus, is a
common cause of irritation and expulsive force. But the fact,
which we most desire to enforce here, is, that when the fetus, in
the operation of turning, is moved in straight lines, and sensibly
displaces the uterine fibers with which it comes in contact, it is
speedily forced back to its original mal-position ; nor can its dis-
placement be easily rectified, except it be moved in conformity to
the curvatures of the cavity in which it is contained. * * * *

" THE MANNER OF PERFORMING CEPHALIC VER-
SION. Suppose the patient to have been placed upon her back,
across the bed, and with her hips near its edge — the presentation to
be the right shoulder, with the head in the left iliac fossa — the right
hand to have been introduced into the vagina, and the arm, if pro-
lapsed, having been placed, as near as may be, in its original posi-
tion, across the breast. We now apply our fingers upon the top of

438

AMERICAN ECLECTIC OBSTETRICS.

the shoulder, and our thumb in the opposite axilla, or on such part
as will give us command of the chest, and enable us to apply a
degree of lateral force. Our left hand is also applied to the abdo-
men of the patient, over the breech of the fetus. Lateral pressure
is made upon the shoulders in such a way as to give to the body of
the fetus a curvilinear movement. At the same time, the left hand,
applied as above, makes pressure so as to dislodge the breech, as it
were, and move it toward the center of the uterine cavity. The
body is thus made to assume its original bent position, the points of
contact with the uterus are loosened, and perhaps diminished, and
the force of adhesion is in a good degree overcome. Without any
direct action upon the head it gradually approaches the superior
strait, falls into the opening, and will, in all probability, adjust itself
as a favorable vertex presentation. If not, the head may be acted
upon as in deviated positions of the vertex, or it may be grasped,
brought into the strait, and placed in correspondence with one of
the oblique diameters.

" It will be observed, that we do not act upon the shoulders by
raising them. Perhaps a slight elevation would facilitate the move-
ment already described — or it might be better to depress them — and,
again, by lateral pressure, without either elevation or depression, our
object might be accomplished. Pushing up the shoulders, therefore,
does not constitute a prominent part of turning, if by pushing up
is meant the mere raising of the shoulders above the brim of the
pelvis.

"As the body of the fetus makes its curved movement under the
hand of the operator, it advances upward, as well as laterally, by a
combined, rather than a single action, which would give it only one
direction.

" The back of the hand, with which we have been acting upon
the shoulder, is toward the head of the fetus — consequently, its hold
upon the head would be apparently slight — yet, after the shoulders
have reached the iliac fossa, the vertex may fall upon the palm of
the hand in occupying the strait, and its adjustment become easy.
If, however, there should seem to be a necessity for grasping the
occiput, there could be no reasonable objection to a speedy change
of hands.

" The entire process of cephalic version is to be adopted in the
absence of uterine contraction ; or, rather, during the intervals of
expulsive force. And, as it is now a vertex presentation, we must

PRETERNATURAL LABOR — SHOULDER PRESENTATIONS. 439

be governed, as to the time and manner of delivery, by those gen-
eral rules applicable to such cases.

" In all our cases, except the one which terminated as a face pre-
sentation, the occiput assumed a position corresponding with the
first or second position of the vertex. In this case the occiput was
before one of the sacro-iliac symphyses, and to this fact we have
attributed the tendency of the occiput to slide above the brim of the
pelvis, and the difficulty in keeping it in place. If there had been
the usual degree of uterine contraction, however, the head would,
in all probability, have become fixed, and the presentation would
have continued as one of the vertex, instead of changing for the
face.

" It will be seen that we lay no claim to the introduction of
cephalic version as a mode of treating wrong presentations, and
expediting delivery. A very brief examination of the subject,
however, nay induce some to award to us originality in respect to
the means by which a successful change of presentation may be
accomplished.

" That cephalic version, by external manipulation — by acting
upon the fetus through the parieties of the abdomen and uterus —
should have few advocates, is not surprising. To be successful, it
confessedly requires a combination of favorable circumstances not
often presented. The tissues both of the abdomen and uterus must
be thin and yielding — the liquor amnii must have been retained,
and in considerable quantity — and the fetus must be proportionally
small.

" In all the obstetrical works we have examined, in which cephalic
version is recommended by internal maneuver, it is directed to raise
the shoulder as the first necessary impression upon the fetus.
Viewed anatomically or mechanically, men have not been per-
suaded into the belief, that raising the shoulder can facilitate the
permanent descent of the head into the superior strait. They claim,
what is apparent to the eye in viewing a proper engraving, and as
it can be demonstrated with the manikin, that the elevation of the
shoulder at the brim of the pelvis, tends to increase the long diam-
eter of the fetus, and the transverse diameter of the uterus, and
without any favorable adjustment of the head after pressure upon
the shoulder has been withdrawn.

" Suppose we follow out the directions given by some, and after
the elevation of the shoulder, attempt to force the body of the fetus
in a lateral direction, will not the breech infringe against the walla

440

AMERICAN ECLECTIC OBSTETRICS.

of the uterus transversely? To enable the head to engage in the
superior strait, the body must be entirely removed from it, and this
can only be done by raising the breech toward the fundus of the
uterus. liaising the shoulder, therefore, is very naturally consid-
ered a means to prevent cephalic version. And we are not sur-
prised that podalic version is almost universally adopted in the
treatment of shoulder presentations.

" If our mode of performing cephalic version is sufficiently clear,
in the description already given, it will readily be distinguished
from others. We claim for it great importance, on the ground
that it is easily executed — that the mother and fetus receive no
injury — that there is little or no danger of subsequent displace-
ment after the vertex has been fully adjusted — that, although it is
most successful in recent cases, delivery may be accomplished after
the membranes have been long ruptured — that it may be executed,
after ineffectual efforts to bring down the feet."

I commend these views of Dr. Wright, together with his
mode of performing cephalic version, to the special attention of
the profession.

CHAPTER XXXIV.

ON PRETERNATURAL LABOR. TRANSVERSE PRESENTATIONS PROLAPSUS OF THE UMBILICAL

CORD PLURALITY OF CHILDREN MONSTERS.

The transverse presentations which follow, are rarely met with,
and some obstetricians have expressed doubts as to the possibility
of their occurrence. However, as they are treated of by several
writers, I have deemed it proper to make a brief reference to
them.

Should the Side of the child present, it may be distinguished
from the head by its want of firmness and roundness, as well as by
the absence of sutures and fontanelles; from the breech, by the
want of the furrow between the two rotund nates, with no coccyx,
anus, or genital organs. The principal discriminating signs of a
side presentation are the presence of two or three ribs, with the
intercostal spaces; and should any doubt exist, the hand should be
passed into the vagina sufficiently to allow two fingers to be carried

PRETERNATURAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 441

fully up to the superior strait. A single intercostal space may be
mistaken for the sagittal suture.

If the child's Back presents, three or four of the spines of the
vertebrae can be detected, and also the origins of the ribs ; and
these may be felt even previous to the full dilatation of the os uteri.

A Sternum presentation may be known by the introduction of
two fingers, which will distinguish the sternal bones, the continu-
ance of the bony plane, the cartilages of the ribs at their origin
from the sternum, and the intercostal spaces.

When the Abdomen presents, there will be felt no osseous promi-
nence, but only the large, soft abdomen, and, perhaps, the ensiform
cartilage may be distinguished, as well as the insertion of the
umbilical cord; though the practitioner must recollect that the
cord itself may present when the abdomen does not, as in prolapsus
of the cord.

It is recommended in all these transverse positions to effect the
delivery by turning, the practitioner being governed in the opera-
tion by the rules given under the management of shoulder pre-
sentations.

A PROLAPSUS OF THE CORD, is where the umbilical cord
presents along with the head, nates, or extremities of the child,
and may be considered under the head of preternatural labor. It
is not frequently met with, having occurred, according to statistics,
437 times in 105,146 cases, or about 1 in 240. Of itself, the falling
of the cord has no influence upon the advance of labor, its small-
ness of size and compressibility offering but little or no hinder-
ance to the passage of any part of the child through the pelvic
canal. The danger is to the child, which, from pressure upon the
umbilical vessels, may die by asphyxia. Until the fetus is expelled
into the world, its life depends upon, and is sustained by, a free
circulation through the arteries and vein of the cord, and any
suspension of this circulation, by compression or otherwise, will
necessarily occasion death, by interrupting the communication
between the child and its mother. We may form some idea of
the peril to which the child is exposed from the statistics of
various authors, in which 245 children were lost out of 392 cases
of prolapse, being considerably more than one-half.

Various circumstances have been referred to as favoring, or
causing a descent of the cord; as mal-positions of the child;
uncommon length of the cord; uterine obliquity; and malforma
29

442 AMERICAN ECLECTIC OBSTETRICS.

tion of the pelvis. A small child, with an excessive amount of
liquor amnii, may contribute to the descent of a loop of the cord,
by allowing the fetal head to move away from the pelvic brim.
When there is a copiousness of the amniotic fluid, the sudden
rupture of the membranes being followed by a forcible gush of
this fluid, may carry with it a loop of the cord; and this would be
more likely to occur should the patient be standing, or in some
other unfavorable attitude when the rupture happens. Prolapse
of the cord may also arise from a want of energetic contractions
of the uterus, in which the fetal head is not maintained with
suflicient power at the superior strait. The attachment of the
placenta near the os uteri, by which the cord is held just at the
orifice of the uterus, likewise favors a prolapsus. Cases have
occurred which were not due to any of the above-named causes,
and which could not be satisfactorily accounted for. Considering
the length of the cord, and the facility with which it moves about
in the liquor amnii, it is somewhat surprising that prolapsions of
it are not more frequently met with.

DIAGNOSIS. — Prior to the rupture of the membranes, it is very
difficult, if not entirely impossible, to detect the cord ; it is only
after the rupture that we can determine its prolapse with any
degree of certainty. The cord then hangs down in the vagina, is
of more or less length, sometimes passing down beyond the vulva;
its roundness, smoothness, and softness may enable the practi-
tioner to distinguish it when in the vagina, and especially its pul-
sations, if the circulation has not been suspended; when it appears
externally, it can be readily recognized.

TREATMENT. — In the management of cases of this character,
various modes of treatment have been advised, but none of them
'have been generally successful. If the cord be cold and flaccid,
with no pulsations, the child will undoubtedly be dead, and as
assistance is required only for the safety of the child, the labor
should be allowed to progress without any interference, unless
called for by other circumstances. We must, however, be cautious
in pronouncing the child's death, for the pulsations may cease
during the contractions of the uterus, and return again as soon as
these have subsided ; beside, instances have occurred where the
pulsations have not been recognized for ten or fifteen minutes, and
yet the child has lived.

The several means recommended by authors, in cases where the
child is known to be alive, are as follows :

PRETERNATURAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 443

1. Returning the prolapsed cord above the superior strait and
the presenting part of the child, and retaining it there until this
has so far descended that any further prolapse will be prevented.
If this could always be accomplished, it would be a very certain
and desirable method ; but, usually, the difficulty is not detected
until after the membranes have ruptured, and the head together
with the cord have been forced down into the brim ; and then any
such attempts would not only prove unsuccessful, but, if persisted
in, might still further increase the difficulty by displacing the head.
Not unfrequently the os uteri may be incompletely dilated, and
then any attempts to return the cord would be impracticable.
When it is fully dilated, the attempt to elevate the presenting
part, or to carry the fingers with the cord between the os uteri and
the presenting part might occasion a return of the pains, and thus
prevent the re-position from being accomplished. Various instru-
ments have beeu presented to the profession for the purpose of
returning the cord ; but I have less confidence in their utility, at
least so- far as I have become acquainted with them, than with the
manual method, by which a few cases have been saved. When
the waters have been freely discharged, and the uterus acts with
energy, any attempts to return the cord will almost always be
unsuccessful.

If the cord can, however, be carried above the presenting part,
by the introduction of the hand in the vagina, and two fingers
into the uterine cavity, I would advise placing it in the axilla, if
possible, or above the knees; and if these can not be effected, to
carry it carefully from one side to the other. However, it too fre-
quently happens, that after the cord has been raised above the pre-
senting part, it immediately prolapses again on the removal of
the fingers. This has sometimes been prevented by introducing
a piece of soft sponge, carrying it upward with the cord.

2. If the head has not entered the pelvic cavity, but is still at
the brim, a resort to turning has been advised, provided the ps
uteri be fully dilated and not rigid ; but as this operation is always
attended with danger to the mother, we should not too hastily nor
too rashly decide upon it. If the soft parts be well dilated, the
pelvis capacious, and the female has given birth to one or more
children previously, the child may possibly be saved by the opera-
tion ; but the accoucheur should always remember that no inter-
ference, of whatever nature, is justifiable, which has for its object

444

AMERICAN ECLECTIC OBSTETRICS.

the safety of the child at the risk of injury or death to the mother.
Where turning has been performed, about seven out of ten chil-
dren have lived : the consequences to the mother are not given.
Merriman advises turning only in instances where the child is
living, as known by the pulsations of the cord, the head not having
entered the pelvis, the parts relaxed and os uteri well dilated, and
the pains weak and inefficient ; and even then it should not be
attempted, unless the practitioner has had some experience in the
operation. Dr. Collins says: "As to turning, the risk to the
mother is, in the majority of cases, so great as to forbid its employ-
ment, nor do I think the practitioner justified by the circumstances
in so greatly hazarding his patient's life."

3. If the head has escaped into the vagina, and the pulsations of
the cord are felt, and especially when they are diminishing or
becoming feeble, the delivery may be hastened and the child's life
saved by a resort to the forceps, and this may be accomplished
with but very little risk to the mother. The forceps must be care-
fully applied, so as not to fix the cord between either of its blades
and the head, and the extraction must be as rapid as possible, but
always consistent with the safety of the mother. Unfortunately,
however, we more frequently find the child destroyed by the com-
pression of the cord, before the instrument can be applied.

4. It has been recommended to place the cord in the angle
formed by the junction of the sacrum and ilium, where it will be
less exposed to compression, and that sacro-iliac symphysis is to be
selected, which will not be occupied by the forehead or occiput.
This has sometimes proved successful, and will probably answer in
cases where the pelvis is large and the head small. In ordinary-
sized pelves but little reliance can be placed in this method.

Of these various modes, the selection must be left to the judg-
ment of the accoucheur, who will determine according to the stage
of the labor, the condition of the soft parts and os uteri, the con-
formation of the pelvis, the presenting part of the child, and
various other circumstances which may be present. In a prema-
ture labor, I should advise no other interference than that named
in method No. 4.

The patient's friends should always be informed of the fact,
when there is a prolapsus of the funis, together with the great
probability of the child's being still-born ; and should she exhibit
any surprise or uneasiness at our uncommon attentions, there is no
harm in acquainting her that " the cord has fallen down, adding,

PRETERNATURAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 445

however, that it will not interfere with the labor in the least, bu
may occasion the child's death ;" nor would there be any impro-
priety in explaining to her the uses of the cord, and the reasons
why the child may be lost.

It is also proper to have the ordinary means for resuscitating the
child in readiness, and which should be used in all instances when
delivery has been effected shortly after the cessation of the pulsa-
tions of the cord, the slightest action of the heart being a sufficient
cause for attempting resuscitation.

Professor Meigs suggests the following measures in prolapse of
the funis, which, however, have not yet been tried by himself :
" Take a piece of ribbon or tape, a quarter of an inch wide and
four or five inches long. Half an inch from the end, fold the tape
back, and sew the edges so as to make a small pocket. Then fold
the other end in the opposite direction, and sew that also to make
a pocket of it. Now, if the cord be taken in the tape, and held
as in a sling, a catheter may be pushed into one of the pockets,
and that one thrust into the other, so that we shall have the cord
held as in a sling, which is itself supported on the end of the cathe-
ter or womb-sound. Let the catheter be now pushed up into the
womb, beyond the fetal head : it will carry the secured portion of
cord with it, and the catheter being withdrawn, the tape is left in
the uterine cavity, where no harm can be occasioned by its presence.
If required, several such tapes could be secured round the cord,
and all of them fixed on the^end of the same catheter, and pushed
at the same moment far up within the cavity of the womb." This
plan may answer in some cases, but I doubt its general application.
Dr. Arneth has succeeded in saving ten out of eleven cases, by carry-
ing up the cord, with the introduction of the whole hand into the
uterine cavity.

In a previous part of this work (page 134), I have made some
observations relative to COMPOUND or MULTIPLE PREG-
NANCY, the signs by which it may be suspected or recognized,
and the several circumstances under which it may be present. At
this place I shall refer more particularly to the management required
for such cases. According to statistics laid down by Churchill in
his work on Obstetrics, 167,676 cases occurring in British practice?
2,572 were twins, or about 1 in 65* ; and 37 were triplets, or 1 in
4,531^. In 36,570 cases in French practice, there were 332 twins,
or about 1 in 110 ; and 6 triplets, or 1 in 6,095. In German prac-

446

AMERICAN ECLECTIC OBSTETRICS.

tice, 251,386 cases gave 2,967 of twins, or about 1 in 84 ; and 35
of triplets, or about 1 in 7,185. The average occurrence of the
whole 455,632 cases, would be 5,871 of twins, or 1 in 77|; and 78
of triplets, or 1 in 5,840. .

In the plurality of children, or where women give birth to two or
more, the danger is always greater than in single pregnancies ; yet
many females are promptly delivered with but little more pain than
in cases where one child is born. The danger in these cases is
owing principally to an over-distension of the uterus ; to a preter-
natural presentation of one or both children ; to hemorrhage after
the expulsion of the placenta, the uterus contracting feebly or not
at all; and not unfrequently, inflammation of the veins and deep-
seated structures of the uterus occurs, terminating fatally.

The mortality to the children in twin births is, according to statis-
tics, about 1 in 3J ; in triplets, 1 in 3. Though it must be recol-
lected that in this calculation the death of the child can not, in
every instance, be attributed to the labor, In 184 twin cases
recorded, 43 were still-born ; and in 240, premature labor occurred
54 times, with 12 cases of a putrid fetus. The fatality appears
to be greater among male children, and especially when they are
twin cases of opposite sexes. These statistics are based upon the
records of various accoucheurs, and may be found in detail in
Churchill's Midwifery.

DIAGNOSIS. — The difficulty in diagnosing twins during preg-
nancy has already been spoken of ; but at the time of labor, after
the expulsion of the first child, the presence of a second can be
positively determined, and it is the duty of the practitioner to insti-
tute a proper examination, that he may have no doubts upon the
subject. A plurality of children may be suspected, from the uncom-
mon size and shape of the abdomen, though it is frequently the case
that in this respect the female is not larger than those who carry
but one child ; from the feeble and irregular action of the uterus,
even after the labor has continued for several hours; and from the
slowness with which the bag of waters is formed. After the deliv-
ery of the first child, its small size may likewise occasion us to sus-
pect that there is another. Yet these various circumstances may be
present, and the case be one of single pregnancy.

It is, therefore, required of the accoucheur, in every case of labor
which he may attend, immediately after the birth of the first child,
to place his hand on the abdomen of the mother, for the purpose of
ascertaining whether there be a second child ; if there be another,

PRETERNATURAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 447

he will find the uterus still hard, large, and unequal ; the fundus
remaining at the epigastrium, or considerably above the umbilicus,
and occupying nearly as much space as previous to the birth of the
first. He should not, however, stop at this external exploration ; it
is absolutely necessary that he positively ascertains not only the
presence of another child, but likewise its presentation and position ;
and to effect this will require an internal examination. Holding the
cord of the first child tense with one hand, but without making any
traction upon the placenta, he will pass one or two fingers of the
other hand along the cord, and if another child be present, the
fingers will come in contact with the second bag of membranes,
when he should correctly ascertain the nature of the presentation,
after which it will always be proper for him to inform the husband
or nurse of the fact ; but it should not be immediately made known
to his patient, lest such a depressing influence on her mind be caused,
as to materially retard the delivery of the second child. No par-
ticular secresy is necessary, but the time of giving ;the information
to the patient, should depend ;'much upon her mental and physical
condition, and the circumstances connected with her case. It may
be proper to observe here, that practitioners have been deceived in
both their external and internal examinations, having mistaken a
large placenta, a large quantity of coagula, an accumulation of blood
behind the membranes of the retained placenta, etc., for the sac of
another child : on rupturing these, the escape of blood or coagula,
instead of the amniotic fluid, wilFat once solve the case.

TREATMENT. — Usually, there are no suspicions of a twin labor
until after the birth of the first child, and the delivery 'may proceed
as favorably as in single cases. But it frequently happens that the
force and frequency of the pains become greatly diminished, in
consequence of the uncommon distension of the uterus; or the
contractions being energetic, the delivery progresses slowly, because
the contracted uterus can not act directly upon the whole of the
body of the child which first reaches the superior strait. And in
cases of premature labor occasioned by twin pregnancy, the deliv-
ery may be delayed, from the immatured condition of the cervix
uteri, which has not undergone those changes which facilitate its
dilatation at full term.

When the practitioner suspects twin labor in a case where the
delivery is proceeding very slowly, and more especially when his
suspicions are strengthened by hearing sounds of the fetal heart
at two distinct locations, he must be very cautious how he ventures

448

AMERICAN ECLECTIC OBSTETRICS.

to administer Ergot, or other agents to increase the action of the
uterus, prior to the birth of the first child : no interference of this
kind is required, or at all necessary. The labor should be allowed
to proceed, no matter how slowly, until the first child is born. But
should any accidents or circumstances offer requiring aid, they should
be treated in the same manner as recommended when they occur in
single labors ; being careful, however, should a resort to turning be
deemed advisable, as in a shoulder presentation, to obtain a hold of
the feet of the right child before making the evolution. If the
children are contained in one sac, or if there are two sacs and both
have become ruptured, a difficulty in relation to this matter will be
very apt to occur. By passing the hand along the external part of
the limbs, until it reaches the breech or genital organs, we may
avoid the mistake of bringing down a limb of each child.

As I have already, when treating on the Management of Labor,
page 278, recommended two ligatures to the umbilical cord, previ-
ous to separating it, it is unnecessary to enter into any especial
remarks upon the subject at this place. After the birth of the first
child, if the presentation of the second is proper, and the contrac-
tions of the uterus continue, no interference is necessary ; indeed, it
not unfrequently happens that the pains are so energetic, and the
expulsion so rapid, that the second child is born before the first can
be separated from its cord. But in cases where there are no pains
after the birth of the first child, or, when they are present, are but
feeble and inefficient, means should be used to forward them, after
having waited some fifteen or twenty minutes. A bandage should
be firmly applied around the abdomen, frictious and compression
should be made over it upon the uterus, and Caulophyllin, Cimici-
fugin, or stimulants, if necessary, should likewise be exhibited
internally. As the passages are already dilated, the exhibition of
Ergot is not objectionable. Should the second child present nat-
urally, that is, either the head or breech presenting at the brim,
and half an hour or an hour has passed since the birth of the first,
the application of the bandage, together with the artificial rupture
of the membranes, will general^ occasion a renewal of the con-
tractions, and delivery will be terminated without any further
interference.

In ordinary cases, where the pains do not return, notwithstand-
ing the means employed, I would not advise the accoucheur to
wait beyond an hour; because the parts being yet soft, dilatable,
and amplified from the expulsion of the first child, the second

PRETERNATUKAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 449

may be expelled with more facility, and with less suffering to the
mother, than would be the case if a longer delay was permitted.
The hour having therefore expired, and no return of uterine
action, the presentation of the second child being known, the
parts being soft and yielding, and the os uteri dilatable, the mem-
branes should be ruptured, and, if necessary, the hand passed
upward to reach the feet, and the evolution proceeded with accord-
ing to the rules already given, being very careful not to empty the
uterus of its fetus before contractions come on. Too sudden an
evacuation of the uterus may give rise to hemorrhage, inversion)
or other accidents.

Turning, however, must never be attempted when the resources
of nature are adequate to the expulsion of the child.

After the delivery of the first child, the parts of the female
being soft and yielding, and also sufficiently amplified by its expul-
sion, a foot or breech delivery of the second child, either natural
or effected artificially, is by no means so difficult or so painful to
the mother, as in similar labors with but one child; nor, as a
general thing, is the safety of the child so greatly compromised.
In a shoulder presentation of the last child, cephalic version,
according to Dr. Wright's method, page 433, might probably be
performed with success.

Sometimes, the female becoming very much fatigued and worn
out by the tediousness of a twin labor, may require artificial aid,
as for instance, with the forceps, for the delivery of the first child;
and in such cases, it will generally be found advantageous as well
as necessary to expedite the delivery of the second by bestowing
similar assistance. Interference will always be demanded during
the expulsion of the second child, when it presents transversely,
or when it is complicated with convulsions, hemorrhages, or other
accidents. And these complications must be combated according
to the rules advised for them, when occurring in single labors.

Hemorrhage is always to be dreaded in twin births, and must be
most carefully watched ; it may almost always be ascertained at an
early period, even before the practitioner would be led to suspect
it from the character of the discharge externally, by closely
observing the expression and color of the patient's face. When
hemorrhage occurs before the birth of the second child, it will
demand prompt action, the labor must be hastened by turning, if
the presenting part is above the superior strait — by the forceps,
when the head is in the pelvic cavity. Hemorrhage after the

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AMERICAN ECLECTIC OBSTETRICS.

birth of the second child, must be treated as hereafter recom-
mended.

Occasionally, there will be a simultaneous presentation of parts
of the two children, as, the two heads, the feet or arms of each, or
the head of one with the extremities of the other, etc. In these
eases, it will be necessary to push up one of the presenting partsf
in order that the remaining one may advance; and should these
double presentations prevent the labor from progressing safely, a
resort to instrumental aid may be demanded, as decapitation of
one child, or such other measures as the exigency of the case may
require.

The practitioner must recollect that in twin labors, one placenta
may be common to both children, or, there may be a placenta to
each child, but connected with each other marginally; and, an
improper management of either of these conditions may occasion
dangerous hemorrhage. No attempts at removing the placenta of
the first child should be made previous to the delivery of the
second, as uncontrollable hemorrhage might thereby be excited.
And, after the expulsion of the second child, a much longer
interval than in ordinary cases must be allowed for the delivery of
the placenta (unless the presence of hemorrhage renders its
prompt removal necessary), as the uterus being somewhat enfeebled
or exhausted, does not so readily renew its contractions as in single
labors. The removal of the placentae must never be effected by
forcible traction upon the cord, but by arousing and securing per-
manent uterine contractions, using frictions and compressions
externally, and making slight tractions upon the cord, as hereto-
fore recommended in single labors.

In hemorrhages, after the birth of the last child, the hand will
require to be introduced within the uterine cavity, in order to
detach and remove the placentae; and it should not be withdrawn,
until a perfect separation of both has been accomplished — and
even then, not until uterine action has been aroused sufficiently to
induce due and permanent contractions of the organ. After the
placentae have been removed, their uterine surfaces should invariably
be examined, to ascertain whether any part has been left behind
within the uterus.

In cases where a premature labor has been induced by the
presence of twins within the uterine cavity, and the first child has
been expelled, the recommendation to rupture the membranes, or
in any way hasten the delivery of the second, is exceedingly

PRETERNATURAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 451

unwise and improper ; this recommendation is only applicable at
full term. After the escape of the first child, should the uterus
cease any further action, the second remaining one may be matured
by a further continuance of the pregnancy, and this result should
always be favored by non-interference, unless accidents occur
threatening the mothers life, and rendering it imperative to empty
the uterus of its contents.

After the expulsion of the placentae, the bandage should be
firmly applied around the abdomen, with a compress over the ute-
rine tumor, to secure its permanent contraction, and prevent any
tendency to hemorrhage; and as the shock to the nervous system
is usually much more severe than in natural labors, the patient
must be kept quiet, the presence of company rigidly prohibited,
and stimulants, antispasmodics, or anodynes, administered accord-
ing to the indications. Uterine hemorrhage should always be
closely watched for, and every means be employed to guard
against it.

Where three or more children are present, they will require to
be managed in accordance with the above rules, recollecting that
the labor will generally proceed slowly, but that the dilatation of
the soft parts will not be so extensive, nor the sufferings to the
mother so great as in labors of one or two children, from the fact
that triplets and quadruplets are usually very small. Hemorrhage,
however, is always to be suspected.

In plural births, every variety of presentation may occur ; thus,
the head of the first child, and the breech of the second, which are
favorable positions ; the head of each may present ; the breech or
shoulder of one, and the head of the other; each child may present
by a shoulder ; together with other varieties, rendering it highly
necessary for the accoucheur to be conversant with the modes
of diagnosticating each and all of them. Cazeaux observes:
"Pleissman states that, on one occasion, he found the orifice
plugged up by the parts that had become engaged, and which at
first sight appeared to him to be a quantity of hands and feet. A
more careful examination enabled him to distinguish four inferior
extremities, which were delivered as far as the hand, and one arm.

" ' At first,' he says, ' I was in great perplexity, because I could
find no way of introducing my hand into the womb, for the pur-
pose of distinguishing and seizing the two feet belonging to each
child, and because all my efforts to make even one of these extrem-
ities go back again, proved abortive ; beside which, in drawing on

452

AMERICAN ECLECTIC OBSTERICS.

any two of them, I might confound and bring down the feet of
two different fetuses at the same time ; and lastly, even if I suc-
ceeded in seizing the two feet belonging to the same infant,
I might, by drawing on them, engage the other parts, and thus
augment the difficulties. Being greatly embarrassed as to the
proper course, and yet obliged to act, the employment of a measure
recommended by Hippocrates, under different circumstances, hap-
pily suggested itself; that was, to suspend the patient by her feet,
hoping that the heads and the trunks of the children would, by
their weight, draw one or more of the extremities toward the fun-
dus of the womb, which was still distended by the waters. The
husband and brother-in-law of the woman passed their arms under
her hams, and thus held her suspended, so that only the head and
shoulders rested on the bolster. I intended, as soon as I mounted
on the bed, to press back one or more of the free extremities into
the womb, but two had already returned from the mere position
of the mother, and the other three soon followed by the aid of my
fingers. Immediately afterward, I was enabled to introduce my
hand into the uterus, and to withdraw successively therefrom three
children by the feet.' In bringing forward this case, I only desire
to illustrate what has been said concerning the difficulty of diag-
nosis. I ought also to allude to the impossibility of the reduction,
and the singular procedure resorted to, with a success that seems
to warrant its employment again under similar circumstances."

Ramsbotham detected, by the direction of the toes, that two feet
presenting at the vulva, a right and left, belonged to different
bodies ; he terminated the labor by making careful traction at one
leg, and gently pushing up the other, extricating each breech from
the pelvic brim, and the children were born living. Such cases,
as before observed, occur when the children are in one sac, or when
the sac of each ruptures before the first child is expelled.

The most difficult complication of presentation is where, as the
first child descends, with the pelvic extremity first, its chin becomes
locked under the chin of the other, which was presenting the
head, and which had passed into the pelvic cavity. In this case
only one child can be saved ; the child which has descended must
be eviscerated and detruncated, leaving its head in the uterine
cavity ; this must be pushed up above the superior strait, the sec-
ond child brought down and delivered, and finally the head of the
first must be removed.

PRETERNATURAL LABOR — TRANSVERSE PRESENTATIONS, ETC. 453

The fetus is subject to various diseases, and to excessive develop-
ment, or perversion of parts, while within the uterus, which may
form MONSTERS or MONSTROSITIES, and which frequently
exert an unfavorable influence upon the parturition. The difficulty
in these cases depends altogether upon the relative proportion
between the fetus and the pelvis; it the child be small, there will be
no delay or trouble in its passage through the pelvis ; if it be large,
from excessive development, or from a union of two fetuses in one,
the labor will be difficult and preternatural according to the dispro-
portion existing and other circumstances which may offer.

Hydrocephalus, ascites, and distension of the abdomen with wind,
or water, are the most common diseases incident to the fetus which
render labor difficult ; these have already been treated upon. (See
pages 353-54.)

Monsters are occasionally met with in practice, and mainly belong
to one of the following classes, viz.: 1. Monstrosity from deficiency
of certain parts of the body, as, in anopses, where the eye and orbit
are wanting; cy elopes, where there is but one eye, situated in the
center of the forehead; acephalous, where the head is absent;
anencephalous, where the head is present, but is devoid of brain,
etc. 2. Double monstrosity, where two or more children become
united together, as in cephalody mia, where the heads grow together ;
hepatodymia, where the livers are united; pelvidymia, where the
pelvic extremities become fused, etc. 3. Monstrosity, or ectopy,
in which one or several parts are abnormally situated. 4. Where
clefts or fissures occur in parts which are united when in a normal
condition. 5. Where there is an excess or disproportionate enlarge-
ment of certain parts. 6. Atresia, or where parts which are
normally opened become closed. 7. Hermaphroditism, or vicious
conformation of the genital organs. Various causes have been
assigned for these monstrosities, among which the most probable
are: 1. A primitive defect in the germs; 2. Accidental changes
undergone by the fetus at some period of its intra-uterine life,
effected by the imagination of the mother, injuries, an unhealthy
condition of the mother, etc.

In an obstetrical point, the only instances which are of interest,
from their sometimes creating a very painful and difficult delivery,
are those belonging to the above 2d, 3d, and 5th, classification, the
2d, more especially; and when they do occur, it is almost impossi-
ble for an accoucheur to form a correct diagnosis. But even
should he be able to detect a monstrosity, it does not follow that

454

AMERICAN ECLECTIC OBSTETRICS.

he should interfere, for the natural efforts are frequently adequate
to the task of terminating labor, and even without loss of the
child's life, as for instance, in the cases of the Siamese twins, and
Rita Christina.

Double monstrosity, or the adherence of two fetuses may be
suspected only by evidence of a negative character. " If two bags
of water are detected by the finger, if it is necessary to rupture
the membranes twice, if the amniotic waters are discharged at two
separate and distinct periods, the presence of independent twins
in the womb may be regarded as certain; for there are never two
envelopes for a double monster, and two perfect twins are very
seldom shut up in the same amniotic pouch. Again, if two feet
or even a single one descend with the head, more particularly if
the feet yield to the tractions made on them, and appear at the
vulva without the heads having a tendency to reascend, we may
affirm there are two infants, because a monster is never composed
of two individuals held together in such a way that the head ot
one is alongside the feet of the other; but if several limbs present
simultaneously, we can only ascertain whether the children to
which they respectively belong are joined together or are inde-
pendent, by carrying the hand up into the womb." (Cazeauz.)

TREATMENT. — The management of monstrosities is similar
to that heretofore named, in cases of difficult labor. A fair trial
should always be accorded to the efforts of nature; if after having
waited a sufficient length of time, say for twenty-four hours, during
which time the pains have been strong and active, if delivery is
not effected, means should then be adopted to expedite it. Or,
should symptoms of exhaustion manifest themselves previous to
this time, or hemorrhage, or other accidents, the accoucheur should
at once interfere. No specific rule can, however, be given; the
general principles of obstetrics must be the guide; the success
attending the case will depend altogether upon the skill and judg-
ment of the attendant, who will resort to the forceps, perforator,
crotchet, etc., according to the peculiar circumstances of the case;
and who should not hesitate to destroy or mutilate the child, if it
become necessary, in order to insure the safety of the mother. In
case of great pelvic deformity, the Cesarean operation may^become
necessary, but, with a normal pelvis, the deformity of the child
must be very excessive, which should lead the practitioner to adopt
this expedient for its removal.

When monsters live, and are capable of action as individuals,

COMPLICATED LABOR — PUERPERAL HEMORRHAGE, ETC. 455

they have the same rights as other persons ; and the destruction of
a monster after birth, however great the deformity, is a criminal
act, punishable as infanticide. This should not be forgotten, as I
have heard of midwives who did not hesitate to destroy monsters
as soon as born.

CHAPTER XXXV.

COMPLICATED LABOR UTERINE HEMORRHAGE FROM PLACENTA PREVIA PUERPERAL

HEMORRHAGE PLACENTAL PRESENTATION.

One of the most common complications of labor, and at the
same time the most alarming, is HEMORRHAGE or FLOODING.
It attacks suddenly, progresses rapidly, and requires prompt and
energetic treatment; equanimity, self-possession, caution, and a
thorough familiarity with the appropriate remedial measures, are
necessary requirements for success — without these the individual
who attempts the practice of obstetrics is extremely culpable. No
one can tell with certainty, in an early 3tage, whether hemorrhage
will occur during any given labor; and it is not unfrequently the
case, that it attacks suddenly and fatally in instances where least
expected; no one can know at what moment he may be called to
treat a formidable puerperal flooding — hence, the importance of
holding the above requirements. A proper attention, may insure
safety to two human beings, while an ignorant or ill-directed
course, is almost certain to terminate fatally.

I have already referred to abortion and the hemorrhage which
may be present in the early months of gestation (page IT I) ; this
may be, and is at times, very profuse, often resulting in the death
of the patient. But the more fearful and perilous attacks of flood-
ing are those which take place at the parturient period. These
may be divided into four forms : 1st. That which occurs at an early
period of labor from placental presentation. 2d. That which
occurs during labor, previous to the birth of the child, but not
dependent upon placenta prsevia. 3d. That which occurs after the
birth of the child, but previous to the expulsion of the placenta.
4th. That which takes place after the delivery of the placenta

In 75,596 cases of labor, hemorrhage occurred 517 times, or
about 1 in 146£; out of 630 cases of hemorrhage, 111 mothers
were lost, or about 1 in 5J ; out of 443 cases, 109 children were

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AMEKICAN ECLECTIC OBSTETRICS.

lost, or about 1 in 4. In accidental hemorrhage, 28 cases proved
fatal out of 114, or nearly 1 in 4 ; in unavoidable hemorrhage 51
cases proved fatal out of 182, or about 1 in 3| ; and in hemorrhage
after delivery 22 proved fatal out of 293 cases, or about 1 in 12.
{Churchill.)

The placenta may vary in its point of attachment to the inter-
nal face of the uterus ; thus, in one class of cases it may adhere to
some portion of the fundus, in another to a part of the body, and
in others over the inner os uteri, and hemorrhage to any great
extent will not take place in either of these conditions, during
gestation or parturition, unless the placenta be considerably separ-
ated from the uterine surface. A slight detachment may occasion
a discharge of blood from some small bloodvessels which have be-
come thereby exposed, but insufficient to create alarm, or amount
to a flooding. It is only when the separation has, from any cause,
become so extensive as to expose the patulous orifices of the large
veins and arteries of the uterus, through which the utero-placental
circulation has been carried on, that a quantity of blood escapes
giving rise to puerperal uterine hemorrhage. And so long as these
orifices remain open, whether from inertia of the uterus, or from
the presence of a body within its cavity which prevents its perfect
contraction and condensation, so long will the hemorrhage con-
tinue. It is only by the contraction of the muscular fibers of the
uterus, that these orifices as well as the caliber of the whole tract
of the bleeding uterine vessels, become diminished to such an
extent as to permanently arrest the flooding. And to adopt means
for the purpose of effecting such uterine contraction is the duty of
every accoucheur who treats puerperal hemorrhage.

HEMORRHAGE FROM PLACENTAL PRESENTATION,
or PLACENTA PREVIA, is termed unavoidable hemorrhage; it
is the most dangerous form, and the most difficult to manage.
The placenta being attached over the inner os uteri, as the fibers
of the cervical portion of the uterine body become more and more
developed during the latter months of pregnancy, in order to en-
large the lower portion of the uterine cavity, the connection
between the placenta and uterus is gradually separated, and the
utero-placental vessels being thereby ruptured or lacerated, a dis-
charge of blood follows, proportionate to the extent of separation
and size of the bloodvessels ruptured. And when this occurs
during labor, the hemorrhage grows more excessive with the

COMPLICATED LABOR— PUERPERAL HEMORRHAGE, ETC. 457

advance of the labor, as each uterine contraction effects an increase
of separation. The placenta may be inserted immediately over
the inner os uteri, so that the centers of the two are in correspond-
ence, or it may vary in any degree between this* central location
and the insertion of its edge near the os internum uteri ; the dan-
ger in these cases increases as the center of the placenta approaches
that of the inner os uteri. The fact that the placenta may lie over the
os uteri, was noticed by several of the older French writers, among
whom may be named Guillemeau, Mauriceau, Amand, Astruc, and
Dionis, as well as by others who have written since the middle of
the eighteenth century. About the year 1728, Daventer called the
attention of the profession in Holland to this matter, and some
twenty-five years later, Bracken and Pugh brought the subject to
the notice of the physicians of England.

Although these writers accurately described the condition of
things at the period of labor, they all seem to have entertained
the opinion that this malposition of the after-birth was owing to
some accident which had dislocated it from its former connection
with the fundus of the uterus, and that it had gravitated down-
ward by its own weight, until it had become placed in its new
position, covering more or less completely the orifice of the organ.

Such an opinion, however, does not obtain with the well-
informed of the profession at the present day, all agreeing, that
inasmuch as the chorion, the decidua, and the membranes, as well
as the bloodvessels, both of the uterus and placenta, maintain the
same relations to each other when the placenta is found in this
position, as when in its normal location, that, from some unknowB
cause it must have been attached from the first, in the lower part
ot the womb, and not have fallen from a former attachment.

As early as in 1730, Giftard published the opinion, that he had
"good reasons to believe that the placenta sometimes adheres to,
or pear, the os internum, and that the opening of it occasions a
separation of the bloodvessels, and consequently a flooding." A
similar opinion was expressed by Heister, in 1739, who said "some
moderns consider as a cause of hemorrhage, the adhesion of the
placenta to the mouth of the womb; so that the more the os uteri
is dilated, the greater i3 the separation of the placenta, and the
more profuse the flooding." In 1761, Leveret, and in 1779,
Smellie, expressed similar views, maintaining that the placenta
was from the first over the os uteri, and that its being there was
not the result of a detachment from the fundus, and a dislocation
30

458

AMERICAN ECLECTIC OBSTETRICS.

of the organ. This opinion has universally prevailed among
scientific men since that time, and now requires no additional
proof to that furnished in abundance by practical men, both by
reason and by observation. For a thorough and satisfactory
explanation of this subject, the profession is indebted to Dr. Rigby,
of Norwich, England.

Instances of placental presentation have been met with, in
which delivery has been safely accomplished by the natural powers
without any hemorrhage whatever, but they are very rare, and are
never to be anticipated. Mo t commonly, the first symptom of
this presentation is a flow of blood occurring sometime during the
"latter months of gestation, from the seventh month to full
term. It is from this period that the cervical portion of the
uterine body begins to rapidly develop itself; a detachment of the
placenta ensues as the uterine fibers expand, and a discharge of
blood follows, which is the first symptom observed. The hemor-
rhage may be so sudden and copious, even at this first onset, as to
prove nearly, if not quite fatal; more generally, however, its first
manifestation is but slight, ceasing if the woman lies down and
remains quiet. This early sanguineous flow, when slight and so
easily checked, is looked upon by the patient as an accident
depending, probably, upon some strain, exertion, etc., and after its
cessation is no more thought of. In five or six days, a further
detachment of the placenta is occasioned by the continued devel-
opment of the cervical part of the uterine body, and a fresh dis-
charge takes place, which is apt to be greater than before; and
from time to time these attacks of bleeding occur, increasing in
severity each time, until, if the woman reach her full term, she
may be so completely exhausted and prostrated from loss of blood,
as to be incapable of sustaining the loss of even a few ounces
more. A woman who has not suffered from bleedings previous to
term, and of strong ^constitution, is more likely to recover, unin-
jured, from a placenta prsevia labor, than one the reverse.

The circumstances under which a vaginal examination must be
made are, 1st, when the hemorrhage is copious and continued;
2d, when the patient has reached full term, or is within several
days of it; and 3d, whenever there are uterine contractions,
however slight they may be, or however distant the intervals
between them.

DIAGNOSIS. — A placental presentation may be suspected when
the first hemorrhage occurs suddenly and without any apparent

COMPLICATED LABOR — PUERPERAL HEMORRHAGE, ETC. 459

cause, being renewed every week or two. If the placenta be
situated above the anterior lip of the os uteri, it will prevent bal-
lottement. At the period of labor it may be suspected by the
increased flooding during a pain, but which diminishes in the
intervals. When it becomes necessary to make an examination
per vaginam, we may then positively ascertain the nature of the
case. I have just stated that an examination of this kind must
be made when hemorrhage is copious and continued, and this
observation applies to all hemorrhages taking place from the
uterus during the latter months of pregnancy. In these cases we
are not to wait for pains, nor be governed by them; for the prob-
abilities are that the uterus has become so enfeebled or paralyzed
from the large quantity of blood discharged that no pains will be
felt — the organ is too weak to contract. Indeed, the absence or
trifling character of pains during these hemorrhages is a most
positive indication of the necessity for interference to learn the
cause of the flooding, and to check it if possible.

In making the vaginal examination it is^ immaterial as to the
position assumed by the patient, provided the fingers can be intro-
duced. The first two fingers may be passed within the vagina, or,
if the os uteri be high up in the pelvis, it may become necessary
to introduce the whole hand. The examination should be con-
ducted with great care, for a quantity of coagula, will generally
be found in the vagina^the separation or detachment of which
will cause a return of the hemorrhage, or increase it in quantity.
Neither should the finger be forced within the os uteri ; if this be
not sufficiently dilated to permit the entrance of the finger without
difficulty, it would be better to wait until the flooding has caused
sufficient dilatation or dilatability.

The placenta will be recognized by the soft, fleshy, fibrous, lobu-
lar sensation which it imparts to the finger, differing from a coagu-
lum by being attached to the inner surface of the lower segment
of the uterine bod}7, and by not being readily perforated or broken
down — a coagulum is loose, can be removed, and may be pierced
by the finger and destroyed without any difficulty. As the exam-
ination will produce a discharge [of blood, the practitioner must
make it a positive one ; he must not allow himself to mistake
a clot, nor the cervix, for the placenta. The latter will have
a thick, spongy feeling; the former is movable and readily broken
down, which is not the case with the placenta. Sometimes the
detached uterine surface of the placenta will be covered by a thick

460

AMERICAN ECLECTIC OBSTETRICS.

smooth layer of coagulated blood, which will prevent the finger
from coming into direct contact with the placenta ; but any error
in diagnosis from this circumstance may always be avoided by
carefully breaking down or detaching the coagulum. Whoever
will carefully pass the point of his finger over the uterine surface
of a recently expelled placenta, whenever the opportunity offers,
will never confound a coagulum of blood, however firm, with
a placenta inserted upon the lower segment of the uterus.

Having ascertained the presence of the placenta, the next inquiry
will be, whether the presentation be complete or partial? If it be
complete, no membranes can be felt; if partial, the edge of the
placenta may be readily detected, together with the membranes
passing otf from it ; — a portion of it may be felt closing a part of
the inner os uteri, and through the membranes may, probably, be
recognized the presenting part of the child. The finger may also
be carefully carried around to ascertain where the placenta is free
or detached, in a complete presentation, but no efforts should be
made to separate it, or to pass the finger between it and the inner
surface of the uterus. Cazeaux gives the following rules for deter-
mining placenta prsevia in certain cases : " When the hemorrhage
takes place either in a woman with her first child, or at an early
stage of the gestation, when, in a word, the cervix uteri is not suf-
ficiently dilated to permit the introduction of a finger, we might
still be enabled to determine the cause of the flooding by the fol-
lowing signs, namely :

" 1. A hemorrhage caused by the placenta's insertion over the
internal orifice never occurs before the end of the sixth month;
and, very frequently, not until the last four or six weeks of gesta-
tion. Beside, it is highly probable that the period at which the
flooding comes on, is usually subordinate to the greater or less
extent of the placenta corresponding to the neck; that, in cases of
insertion, center for center, it is manifested much sooner than
where only one of its margins is in opposition with the orifice.
Nevertheless, there are numerous exceptions to this (as M. Nsegele
considers it) nearly general rule ; for, in a large number of the
•ases of central insertion, the hemorrhage is not developed prior
to the commencement of labor.

" 2. It commences spontaneously, without an appreciable cause,
and without any precursory phenomena ; the woman being often
suddenly aroused in the middle of the night by the blood escaping
from the genital parts.

COMPLICATED LABOR — PUERPERAL HEMORRHAGE, ETC.

461

"3. "When manifested for the first time, it is generally inconsid-
erable in amount and soon over ; but, after having disappeared
altogether, it returns, sometimes in the course of a few hours, at
others, not for several days ; and, at each reappearance, the dis-
charge is a little more abundant, and, lasts somewhat longer.

"4. The cervix uteri (considering the period of gestation) is
usually thicker, softer, and more spongy, because the placenta, by
becoming fixed over this point, determines there a more consider-
able afflux of blood.

"5. If the labor has commenced, and the membranes are still
intact, the flooding constantly augmeuts during the uterine con-
tractions, aud diminishes in the intervals. But the contrary is
observed when the discharge is occasioned by a separation of the
placenta attached to any other point ; for then the womb, by con-
tracting, obliterates the vessels, either by a retraction of its own
proper tissue, or by the compression they are subjected to from the
parts inclosed within its cavity ; but, in the case under considera-
tion, the contractions that affect the dilatation of the cervix,
destroy the vascular adhesions which unite it to the placenta,
more and more, and thus multiply the sources of hemorrhage.
This sign is one of great value before the membranes are ruptured;
but, after the waters are discharged, the child's head presses on
the orifice during the contraction, and prevents the blood from
escaping.

"6. The bag of waters does not form as in an ordinary labor ;
for the insertion of the placenta over the neck closes its orifice,
and prevents the lower segment of the ovum from engaging
therein, and from being accessible to the finger.

" 7. Lastly ; according to Dewees, the blood has a brighter color
at the onset of the hemorrhage than when it comes from the fundus,
and coagula never comes away, excepting when the discharge haa
lasted for some time, or is on the point of disappearing."

TREATMENT. — The treatment of cases of placental presenta-
tion will depend much upon the period at which the practitioner is
called, as well as the attending circumstances. If called some
weeks previous to full term, on the occurrence of the commencing
floodings, and these are not very copious, the only measures
required will be to keep the patient in a horizontal situation, on a
hard bed and in a cool room, enjoining rest and perfect quiet; and,
as in all cases of uterine hemorrhage, the bed should be placed so
that the attendants can easily pass around it : internally, cold and

462

AMERICAN ECLECTIC OBSTETRICS.

acid drinks may be exhibited, and cold water or some cold astrin-
gent solution may be injected into the vagina. The covering
should be light, and the bowels mii3t be kept regular. Iu fulfilling
this latter indication, care must be had not to effect active catharsis
by internal agents nor by stimulating enema, as these will have a
tendency to increase or cause a return of the hemorrhage — a con-
sequence of straining or tenesmus, which may produce a removal
of the coagula which are covering the lacerated bloodvessels. An
injection of cold water is probably the be3t agent which can be
employed to free the rectum, and it should be repeated, according
to circumstances, once or twice daily, or every other day. Not
unfrequently there will be more or less nervous irritability, gener-
ally arising from an excited and alarmed condition of the mind.
The practitioner should always endeavor to tranquilize any mental
agitation which may be present; and, to allay the excited condition
of the nervous system, he may administer some compound powder
of Ipecacuanha and Opium, or a pill of Opium, or some tincture of
Hyoscyamus, either of which may be found beneficial. The diet of
the patient must consist of light, nutritious fluids, avoiding all stim-
ulating agents of whatever character, and this should be persisted
in as long as may be deemed proper or necessary.

The hemorrhage having ceased, it must be borne in rnind that it
is liable to return at any moment, and may prove to be very
excessive and serious. Before leaving the house, therefore, full
instructions should be given to the friends for its management
during the accoucheur's absence, as for instance, the above measures,
with applications of cloths to the vulva, wet with cold water and
vinegar. He should likewise strictly enjoin upon them to send for
him instantly on its recurrence ; and lest he may not be readily
found, the services of another professional brother should be
secured, in order that the female may not perish for want of proper
attention. Beside, these measures show that the practitioner feels
a deep interest for the welfare of his patient, secure her confidence
as well as that of her friends, and add to his reputation. As soon
as the causes of the hemorrhages are suspected, the friends of the
patient should be informed, and the dangers to which she is exposed
fully made known ; but on no account should the patieut be notified,
lest it might hasten an unfavorable issue, by creating an intense
nervous excitability with powerful mental agitation.

Should the hemorrhage be excessive, aud resist the energetic
measures employed to check it, or should uterine contractions, how-

COMPLICATED LABOR — PUERPERAL HEMORRHAGE, ETC. 463

ever feeble, be experienced, with even moderate loss of blood, the
practitioner should apply ligatures to the inferior extremities, and
then proceed to a vaginal examination, as heretofore explained. If
the os uteri be found rigid, resisting the introduction of a finger,
no force whatever must be employed; the os uteri must be soft
and yielding, in all cases, before any introduction of a finger or of
the hand is to be attempted — to do otherwise is unpardonable.
There may be cases, where the hemorrhage is very copious, with a
rigid and unyielding condition of the parts forbidding the introduc-
tion of a finger for diagnosing, or of a hand for version, in which
this rule may be violated, for the purpose of endeavoring to afford
the patient the only chance for safety ; but it is always hazardous,
and most frequently terminates fatally. Generally, however, the
rigidity of the os uteri will be speedily overcome by the great loss
of blood.

In placenta praevia, the danger is from hemorrhage, which
increases when uterine contractions come on, or when dilatation of
the os uteri is progressing; and the great and important question
is, when to deliver? The established, and probably the safest
method of delivery is, by turning and promptly bringing away the
child. The operation has its dangers, but it is the best which can
be pursued, and its success will depend greatly upon the skill and
judgment of the accoucheur. If he waits for the complete dilata-
tion of the os uteri before undertaking the operation, the exhaustion
effected may be so great as to afford no hope for the patient's sur-
vival, or she may perish before such dilatation is effected. I would
repeat, therefore, two great principles by which all medical men
must be guided in their management of placenta prsevia: 1, never
attempt to pass the hand within the os uteri when it is in a rigid
condition ; 2, never delay interference by version or otherwise, until
full dilatation of the cervical orifice has been accomplished.

The time for operation has arrived, when the os uteri, being soft
and yielding, has dilated to the size of a half dollar, or sufiicient
to easily admit the introduction of the points of the fingers and
thumb : to wait for a greater enlargement of the orifice, would be
to increase the hazards to the patient, because the hemorrhage
becomes more and more copious and alarming as the development
of the os continues to advance; to interfere sooner, would be at
the risk of effecting considerable injury to the os uteri.

The requisite amount of dilatation having been accomplished,
the femaie should be placed upon her back; or if the hemorrhage

464

AMERICAN ECLECTIC OBSTETRICS.

bo excessive, or she be very much exhausted, she must not be
moved, but the version must be effected while she is lying on her
left side. The pelvic extremity of the patient should, if possible,
be considerably elevated above the head, so that the body shall lie
in an inclined position, the head being the lowest part, and this
may readily be effected by lifting up the bedstead aud securing the
legs of one end on blocks of sufficient hight : this measure may
preserve her from a fatal syncope. The operator must remove his
coat, bare his arm, and having anointed the arm and fingers, pro-
ceed to the introduction of the hand into the vagina.

Before introducing the hand, however, it is of some importance
to ascertain the position of the child ; for should the wrong hand
be employed at first, its removal will produce an increase of the
flooding, and which may involve fatal consequences before the
other hand can be entered. If the placenta be only partially at-
tached over the inner os uteri, or if one side of it be wholly
detached, the finger may be passed between the free end of the
placenta and the uterus until it reaches the membranes, when the
position may be ascertained through these; or if this can not be
done, and the patient be not too corpulent, an external examina-
tion over the abdomen, in the absence of pains, may detect the
globular head at the lower portion of the belly, and the curve of
the child's spine being found on the right or left side, will deter-
mine its position. This can not, however, be easily ascertained in
all cases, and the practitioner will then employ his left hand, on
the presumption that the head is in the most usual position, or
that in which the occiput looks toward the left acetabulum.

"In every case, before attempting to turn, make a most careful
examination of the os uteri, and endeavor, from the degree of dila-
tation, and the thinness and softness of the orifice, to form a cor-
rect judgment upon its dilatability before interfering; for if your
attempt be unsuccessful, the hemorrhage will be renewed, and the
patient will be placed in a worse condition than she was before." —
(Lee.)

The fingers and hand are to be slowly and carefully passed within
the vagina, in a conical form, as heretofore explained (page 424),
and carried up to the os uteri. As the fingers are insinuated within
the os uteri, they should also gently dilate it, advancing upward
between the free or detached side of the placenta (which must be
detected by a careful exploration, as already referred to), and the
inner surface of the uterus. If the placenta be not sufficiently

COMPLICATED LABOR — PUERPERAL HEMORRHAGE, ETC. 465

separated to admit of the entrance of the hand, an artificial separ-
ation must be cautiously effected, selecting, when possible, that
side of the placenta for the detachment which is ascertained to be
the thinnest, which will be the nearest to its edge, and where, con-
sequently, the uterine bloodvessels will be the smallest. As soon
as the fingers have entered the os uteri, a greater or less discharge
of blood will almost always follow, but at which the practitioner
must not be alarmed; firmness, self-possession, and gentleness are
required ; and should the practitioner, alarmed at the fresh dis-
charge, attempt the withdrawal of his hand at this time, a fatal
increase of it would very probably be the result. As soon as the
hand has thoroughly entered the uterine cavity, the wrist or arm
prevents any further material loss of blood, by compressing the
orifices of the bleeding vessels.

The hand should be passed as high up between the uterus and
membranes as possible — these should then be ruptured — the hand
carried within, and the feet of the child be obtained. If both feet
can not be readily found, the version may be effected by one only,
instead of delaying the delivery by a prolonged search for the
other. The version should be carefully effected, but with as much
expedition as is consistent with the safety of the child and patient,
and the limbs should be brought down into the vagina until the
hips or body of the infant is in contact with the uterine cervix ;
and this is to be performed, not only to facilitate delivery, but that
the compression of the bleeding vessels by the fetal pelvic region
may check any excessive hemorrhage.

A sudden removal of the contents of the uterus might give rise
to inertia of the organ and fatal flooding; therefore, unless the
copiousness of the discharge requires the immediate delivery of
the child, this must not be effected. And in every case of hemor-
rhage from placental presentation, as soon as the version is com-
pleted, a full dose of Ergot should be administered, not so much
for the purpose of aiding in the expulsion of the child, as to secure
permanent contractions of the uterus subsequently. For it must
be remembered, that the life of the patient depends entirely upon
perfect and persistent uterine contractions. Beside the Ergot,
frictions, and other means which have been heretofore spoken of,
to arouse or preserve the action of the uterus, may be employed.
The bandage should never be omitted.

Some writers recommend the perforation of the placenta itself
but this is a very difficult operation, and when accomplished, may

466

AMERICAN ECLECTIC OBSTETRICS.

effect the death of the child and mother from augmented hemor-
rhage occasioned by the certain rupture of large bloodvessels ,
or from a delay or difficulty in the passage of the child through the
insufficient opening made by the hand. It should never be
attempted.

The practitioner may, however, be called to a case of this nature,
where the hemorrhage is copious and frightful, before the os uter1
is sufficiently dilated, and in which delay would be death. If the
os uteri be found rigid and unyielding, no attempts at forcibly
entering it with the hand are justifiable — such attempts are always
dangerous. The only course to be pursued is to procure, if pos-
sible, a diminution of the discharge, until the os uteri is in a more
favorable state. For this purpose, ligatures should be applied to
the extremities, the patient should be kept quiet in a recumbent
position with the hips slightly elevated; vaginal injections of cold
water, or cold astringent solutions, with cold applications to the.
external parts, nates, thighs, etc., should be persistently employed
Cold, acidulated, or astringent draughts should be administered
internally, and the vagina may likewise be plugged with a tampon
wet with a solution of Alum, and which will occasionally be found
useful. In the early part of this work I stated that the tampon
was not to be used in hemorrhages from the uterus, occurring after
the fifth or sixth month. The present instance may, however, be
considered an exception, as there can not be a concealed hemor-
rhage to any great extent so long as the membranes remain entire,
and the cavity of the uterus is not in a condition to receive a large
amount of blood, except such as may pass between the inferior
part of the membranes and the cervix, unless, indeed, the organ
be in a very lax condition with great prostration of the vital
forces. Beside, the use of the tampon does not dispense with the
careful watching of the patient, observing the features, the pulse,
etc. When no unfavorable symptoms follow the employment of
the tampon, its removal will be indicated by the strength and
frequency of the pains. I do not recommend the use of the
tampon in partial placental presentation, but only in those
instances where the membranes can not be reached on account of
the internal orifice being wholly occupied by the after-birth. In
many instances, notwithstanding the use of all the above measures,
the flooding will continue unrestrained ; it then becomes necessary
to hasten the delivery by all possible means. Generally, the
rigidity will be speedily subdued by the great relaxation produced

COMPLICATED LABOR — PUERPERAL HEMORRHAGE, ETC. 467

by the excessive loss of blood, when the following course may be
attempted :

But if, instead of a rigid condition of the os uteri, a soft, dila-
table one be found, however small the opening, the hemorrhage
being, as abovejremarked, frightful, the fingers may t)e carefully
entered within the orifice one by one, gradually dilating it as they
proceed, until the hand can be so far introduced as to effect the
version. This is not a desirable method, neither is it of easy per-
formance, and being always, more or less hazardous, should never
be undertaken except under imperative circumstances; it then
becomes the best and only course left us, and should be employed
with all the precautious which a knowledge of its disadvantages
and dangers would suggest. In these frightful cases a delay may
be fraught with fatal results. "As a principle, delivery had better
be had recourse to an hour too soon than an hour too late." "-It
is the loss of the last half pint of blood that kills the patient."
"Sometimes, when in these cases, it is impossible to pass the whole
hand through the os uteri, the delivery may be safely accom-
plished by merely passing one hand into the vagina, and afterward
the fore and middle fingers between the uterus and detached por-
tion of the placenta, grasping with them the feet, which are
generally situated near the os uteri, and drawing down the inferior
extremities into the vagina and delivering." — (Lee.)

In these cases, the physician should always have his forceps at
hand, in order to extract the head, should any delay or difficulty
occur in its delivery.

When the placental presentation is PARTIAL or INCOM-
PLETE, that is, when its edge extends only to the margin of the
inner os uteri, or perhaps, covering one-third, one-half, or any
other proportion of this orifice, the remaining part presenting the
membranes, symptoms of a character similar to those in complete
placenta prsevia will be met with, requiring a somewhat analogous
treatment. This form of placental presentation is of more fre-
quent occurrence than the complete.

When labor i? on, and the hemorrhage is profuse, the best course
is, to rupture the membranes, without regard to the extent of
dilatation of the os uteri, which, by allowing the liquor amnii to
escape, will permit the head or breech, as the presenting part may
be, to descend and compress the bleeding orifices, thereby check-
ing or diminishing the flooding. At the same time, the tincture
of Gelseminum may be exhibited to forward the dilatation of the

468 AMEKICAN ECLECTIC OBSTETRICS.

og uteri, while the bandage may be applied, and other means used
to cause vigorous uterine contractions; and at the proper period,
Ergot may be given to facilitate the expulsive process, but this
druff must not be administered when the natural efforts are all-
sufficient, except it be for the purpose of securing permanent con-
tractions after the delivery.

Should this course fail, the hemorrhage continuing, or, should
there be exhaustion of the system, from the amount of blood lost,
the better plan will be, to rupture the membranes and turn, being
governed by the rules already laid down for version in complete
placental presentation.

In case the liquor amnii has been discharged, and version is
desirable, the hand will find but little difficulty in entering within
the uterine cavity, because, the excessive flooding will effect a lax,
yielding condition of the parietes of the organ ; this is unlike pre-
ternatural presentations, in which "a loss of the amniotic fluid is
followed by energetic contractions, rendering it almost impossible
to introduce the hand for the operation of turning. Beside, in
placenta prsevia, should the contractions be sufficiently vigorous to
advance the head, the. pressure made by it on the orifices of the
vessels will diminish the flow, and there will then be no necessity
for the introduction of the hand, as the delivery will be effected by
the natural powers, except indeed, the pelvis be malformed, or the
soft parts be rigid and unyielding.

In preternatural presentations of the fetus, with placenta previa,
or in a small or deformed pelvis, it will be proper to turn, pro-
vided the hand can be introduced for the purpose — and, in the
latter instance, when the head can not descend, or pass through
the cavity and inferior strait, it will require the use of the perfora-
tor to terminate delivery.

The treatment after delivery will be in accordance with the rules
hereafter given, endeavoring to produce persistent uterine contrac-
tions which will prevent a return of hemorrhage — also to sustain
strength, and allay the irritable condition of the system.

COMPLICATED LABOR — SYNCOPE FROM HEMORRHAGE, ETC. 469

CHAPTER XXXVI.

COMPLICATED LABOR. HEMORRHAGE PROM PLACENTA PREVIA {Continued) — SYNCOPE

FROM HEMORRHAGE.

In hemorrhage from placental presentation, as well as in all
puerperal hemorrhages, there is one very important symptom to
which the attention must be especially directed — I mean SYN-
COPE, or a state approaching to it. When the female has lost
a large amount of blood the practitioner will probably find her
pale, cold, and gasping, the uterus torpid and exceedingly flabby,
the pulse nearly gone, with a fluttering of the heart, and a greater
or less degree of insensibility. Upon an examination the flow of
blood will be found suspended ; but in making the examination,
when the above symptoms are present, the greatest care must be
had not to disturb the patient, or pass the finger into the vagina —
it must be ascertained from the appearance of fresh cloths applied
to the external parts. In suqh cases, the patient must not be
moved — a change of position frequently results fatally; neither
must an}' manual operations be performed for the purpose of
emptying the uterus or otherwise endeavoring to promote its con-
tractions. Should the patient be not altogether insensible, she will
manifest an intolerable restlessness of disposition, a desire to
change her posture, which, if acceded to, will occasion sudden
death. If the hand be introduced within the uterus, for any
purpose whatever, a disturbance of the coagula will immediately
renew the flooding, and sudden death will almost certainly take
place.

Instead, therefore, of rendering useless attempts at any manual
operations, the practitioner should employ measures to rouse the
sinking system, and sustain the strength of his patient, until she
has so far recovered, that, attempts may be made to empty the
uterine cavity, if necessary. And to accomplish this indication,
stimulants must be given. Brandy, Rum, Ether, Ammonia, or
other cordials may be administered. If the spirituous preparations
be used, it is better to give them undiluted, if the patient can bear
it, because it will require a less amount of fluid to be thrown into
the stomach, and this organ will be less likely to reject it. These
stimulants must be persevered in, until they have exerted a decided,
but not too highly stimulating influence upon the system as man-
ifested by an increase of the pulse, an augmentation of the tern-

470

AMERICAN ECLECTIC OBSTETRICS.

perature of the extremities, a reddening of the lips, and a return
to consciousness; and when these symptoms present, the further
exhibition of stimuli ma}' be dispensed with. In cases of this
character the stomach will be nearly as insensible as the rest of the
system, and will not be so readily acted on by these cordials as
when in a more healthy and vigorous condition ; one or two fluid-
ounces of undiluted Brandy may be given at a dose, and repeated
every five, ten, or twenty minutes according to the degree of
depression of the vital powers.

But, not unfrequently, with the fainting or syncope, there may
be a continued flow of blood ; this is a very serious condition,
especially if the female be sinking rapidly. Under1 these circum-
stances, the object will be to suppress, if possible, the hemorrhage,
and for which it is difficult to give any specific rule. The rupture
of the membranes followed by a discharge of the liquor amnii, or
the removal of the fetus, or the delivery of the placenta, may either
of them be followed by contractions of the uterus, and a conse-
quent suppression of the flooding, and thereby prove the safest
course to adopt; while on the other hand, and particularly if the
female be much exhausted by the drain from the system, and the
syncope be long-continued or extreme, the wiser course will proba-
bly be to refrain from all operations, trusting to the natural
resources aided by the general external and internal measures
usually employed in severe hemorrhages, without any disturbance
of the patient's position.

From the infrequency of placenta prsevia, it may be considered
that too much space has been occupied with its nature and treat-
ment; but, if a trial of the means herein named will contribute to
the preservation of but one life, it will amply repay for the time
and space accorded.to it. And, that the reader may be well posted
in the management of this difficulty, at the risk of some repeti-
tion of what has been just stated, I give the following valuable
remarks upon its treatment.

* * * It is probable, that the accoucheur meets with no
other condition of affairs, demanding a more thorough acquaint-
ance with his profession — more prompt action, or cool intrepidity,
than when called to a case of placental presentation; and hence
the necessity for a careful and somewhat full delineation of all
the circumstances that may attend this form of complicated labor.
From the nature of the case, it will be apparent that in placenta
prsevia, there must be a greater or less loss of blood, at any time

COMPLICATED LABOR — SYNCOPE FROM HEMORRHAGE, ETC.

471

when the os or cervix uteri dilates or develops itself, and that
several repetitions of these floodings, or, even one, if it he suffi-
ciently copious, may not only induce great prostration of the vital
powers hut may prove destructive to the life of the patient. * * *

Should the placental mass he soft and tender — the os dilate rap-
idly, and the expulsive power of the uterus he sufficient, the head
or any other presenting part of the child may he pushed through
the placenta, and then its presence within the pelvis, may so
lessen the diameters of that canal as greatly to embarrass the
further progress of the labor, and, perhaps, endanger the life of
the child. Or, as the os uteri dilates, the placenta may be entirely
detached from the uterus, and be expelled — the child, probably,
dying before it can be delivered either from hemorrhage through
the umbilical cord, or from the want of the vital power it has
been accustomed to receive from the circulation of the mother.

If relief be not afforded, a fatal termination may be anticipated
in the great majority of cases, and hence the necessity for knowing
how to detect the danger at the earliest period, as well as to kuow
how to manage the case when its nature is ascertained. * * *

Although it might be supposed that the duties of the accoucheur
only begin with the commencement of labor, yet such is not the
fact in cases of placental presentation. When we consider the
location of the cake, as has been, detailed, over the os internum,
and recollect the changes which occur in the lower segment of the
uterus atter the middle of the sixth month, we shall perceive that
frightful hemorrhage may suddenly occur at any time, even during
sleep, and the physician may be sent for on the supposition that
labor has already commenced.

These accidents may, and frequently do occur repeatedly during
the last few weeks of pregnancy — and the gush of blood may
repeatedly be mistaken for a rupture of the membranes and a flow
of the liquor amnii, and the error only discovered by the physician
finding the underclothing drenched with blood. When this acci-
dent occurs without any unusual mental or physical exertion,
during the last weeks of gestation, the possibility of dislocation of
the placenta should he born in mind, and proper admonition bo
given the patient and her friends. If it has occurred two or three
times, the probability of a presentation of the placenta becomes
very strong, and the danger attending this untoward state of affairs
within the uterus should be explained to the friends of the patient,

472

AMERICAN ECLECTIC OBSTETRICS.

and the strictest regimen, both mental and physical, enjoined with
all the authority of — the physician.

It is useless to make vaginal examinations by the speculum, or
otherwise, as, the difficulty being within the cavity of the uterus,
and the os undilated, no information can be gained by these man-
ipulations, but the woman may be seriously injured by them.
Neither can much be gained by local applications in the vagina, or
rectum, except by the application of cold, as the injection of cold
water.

The hemorrhage previous to full term being mainly from the
vessels of the placenta (for the very act of development on the part
of the uterine neck, which separates the placenta, tends to close the
ruptured vessels within its walls), but little benefit can be derived
from the application even of cold, and any astringent, styptic, or
sedative medicine can be absorbed into the general circulation far
more readily and promptly from the stomach, than from the rec-
tum or vagina.

But the physician can take off the pressure of blood upon the
ruptured vessels. He should not bleed, as has been recommended
by some authors, because the vitality of the system is already more
than sufficiently reduced; and the loss of blood, whether from the
uterus or the arm, only makes that -fluid thinner and less capable
of forming the necessary clot to plug up the ruptured vessels : but
he should at once (if the hemorrhage has not ceased before his
arrival) ligate both limbs high up around the thighs, and then
apply stimulants and warmth to the extremities, to invite into the
limbs and to retain there as much of the vital fluid as possible. By
these means a large amount of blood may be withdrawn from the
general circulation, and kept in reserve for use after the immediate
danger has passed.

At the same time, astringent medicines should be administered,
and for this purpose Alum is probably unequaled; for, being very
soluble, it is readily absorbed into the circulation, and acts both to
astringe the muscles of the bloodvessels and to coagulate the \
albumen of the blood, so that while it lessens the orifice of the
bleeding vessels, it also aids in the formation of the clot to plug
them up. To insure its absorption into the circulation, it should
be given in a solution with sufficient water, whose specific gravity
does not exceed twenty degrees above that of water; for should it
be over twenty-five or twenty-six degrees heavier than water,
instead of passing through the coats of the stomach and entering

COMPLICATED LABOR — PLACENTA PRJEVIA.

473

the circulation, it will cause endosmose of the blood serum, and
induce either emesis or catharsis.

The Alum, then, should be administered in not too large doses,
say from ten to fifteen grains in a wineglassful or more of water*
and repeated as often as the attendant thinks it is absorbed from
the stomach.

At the same time, a sedative to the heart should be adminis-
tered, and for this purpose Opium is usually chosen. As it puts a
stop to the flooding, it has acquired the reputation of being an
astringent, but we have no evidence that it possesses such a power.
It docs act upon the vagus and the sympathetic nerves as a sedative,
lessening the force and frequency of the heart's contractions, and
hence lessens the pressure of the blood upon the ruptured vessels,
and in this way tends to check the flooding. Were it the only
agent we have which acts thus, or were it not liable to induce
other and unfavorable changes in the system, it would be invaluable
in these case3 ; but we do possess other agents even superior to it in
their power of controlling the muscular contractions of the heart,
while they are not obnoxious to the grave objections that obtain
against the use of Opium.

Of the sedatives to the heart, the tincture of Gelseminum is the
most powerful one known to the profession, and does not appear
to possess a single objectionable property. It should be adminis-
tered in full doses, say from ten to twenty drops, and in some
cases even more, and the dose repeated every fifteen or thirty
minutes, until the muscular system and the heart are strongly
controlled by it. The practitioner should not fail to remember
that the speed with which medicines are absorbed, and produce
their effects, is greatly enhanced by the loss of blood; and he
should also bear in minfl that the greater the loss of blood, the
smaller will be the dose required to produce an influence. Espe-
cially is this true of all sedative medicines; and many patients
have been destroyed by abstracting blood from them while suffer-
ing from the depressing effects of a dose of Opium.

Should the physician discover that the loss of blood has so
enhanced the action of his sedative as to produce unnecessary
depression, he should at once administer the Carbonate of Ammo-
nia, in proper doses, as a stimulant. He must not give Alcohol in
any form, for it tends to liquefy the blood, and, also, secondarily
will prove a sedative instead of a stimulant.

Absolute quiet in the horizontal position, on a hard bed, and in
31

474

AMERICAN ECLECTIC OBSTETRICS.

a cool room, with as little covering as will prevent suffering from
cold, must be strictly enjoined, and the ligatures must be retained
around the limbs, changing their location as may be demanded,
until the present danger has entirely passed. No stimulating food
or drink, nor any sources of mental excitation, may be indulged
in, but cool drinks and mild, nourishing food may be taken in
sufficient quantities to satisfy the demands of the system. No
violent purgings or other undue excitations are admissible, but the
bowels should be kept soluble by the daily administration of the
requisite amount of Seidlitz powders, or some other saline laxa-
tive, which will tend to abstract from the blood its more fluid
portions.

As a return of the hemorrhage may occur several times previous
to confinement, and is almost certain to be present to an alarming
extent at that time, it will be proper that another physician
be called in, to whom the nature of the case and the plan of treat-
ment are made known, so that should the attending physician be
deterred from visiting at any time, this professional friend may be
prepared to carry out his plans.

Such are the modes of treatment demanded in those hemor-
rhages that occur previous to the commencement of labor.

When the full period of gestation arrives, the mouth of the
womb will begin to dilate, and more bloodvessels will be ruptured, so
that the hemorrhage will probably be more profuse than at previous
attacks; and as the labor continues to advance, it will not cease
so speedily nor so readily as in former times. As soon, then,
as the flooding is accompanied with labor-pains, a cautious but
thorough examination should be instituted, the limbs should be
ligated as before directed, the patient should be placed in a hori-
zontal position, the tincture of Gelsemmum should be adminis-
tered, both to quiet the heart's action, and to produce relaxation
of the muscles of the lower' half of the uterus, so as to allow
dilatation to proceed as rapidly as possible; and having the proper
instruments in readiness, and, if possible, the attendance of a
friendly physician, the accoucheur should, as soon as the os uteri
has dilated so as to admit the points of his four fingers, proceed to
introduce his hand into the vagina, and as fast as possible, without
too great violence, into the uterus, not through the placenta, but
carefully separating this organ from the uterus and cautiously
pushing his hand forward until it is within the uterine cavity.
Then, without delay, he should rupture the membranes, and pass

COMPLICATED LABOR — PLACENTA PREVIA.

475

his hand up until he can grasp one or both feet; or if he can not
reach these, he may seize the knees, and turning the child, the
labor must be hastened as rapidly as possible.

If the patient be of spare habit, the position of the child may
sometimes be ascertained with considerable certainty by an exter-
nal examination over the abdominal protuberance ; but if nothing
can be determined in this manner, the practitioner is to proceed on
the supposition that the child lies in the natural position, with the
vertex to the left acetabulum, and face to the right sacroiliac
symphysis.

The modus operandi of -turning, in cases of placenta prsevia, does
not materially differ from the same operation in other conditions.
I prefer the woman to lie on the left side, and the hips near the
front of the bed, and well elevated — both because there is thus
more freedom in manipulating, and because the danger from hem-
orrhage is lessened as the hips are elevated, and the head, trunk,
and extremities depressed. The hand is to be formed into a coni-
cal shape, the fingers being drawn to a point, and it is to be passed
to that side of the uterus where the placenta is most easily detached,
and then introduced high up within the uterine cavity before the
membranes are ruptured, in order to allow as much of the waters
to remain in the sac as possible, until after the version of the fetus.

Previous to the manipulation, a dose of Ergot, or some other
special stimulant to the uterus, should be prepared, so that as soon
as the feet and limbs are drawn through the os uteri into the vag-
inal cavity, it may be administered for the purpose of insuring the
uterine contractions with the further descent of the child. Not
only should the Ergot be given as soon as the feet are brought down,
but pressure and gentle friction should be applied to the uterine
tumor through the abdominal walls — care being exercised not to
press the fundus of the uterus into its own cavity.

The operator should bear in mind, that after he has passed his
hand within the uterus and separated the placenta from its attach-
ment, delay, or hesitation, or a withdrawal of his hand, will be
almost certainly followed by fatal hemorrhage ; and that the safety
of both mother and child will depend in a great degree, on his firm-
ness, presence of mind, and knowledge ; and, regardless of the views
or pleadings of the patient or her friends, he must firmly persevere
until delivery is effected, unless some very extraordinary difficulty
shall prevent.

I well know that many entertain a strong and honest prejudice

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AMERICAN ECLECTIC OBSTETRICS.

against the use of Chloroform in labor, but from a not very limited
experience of its use in my own private practice, as well as from
the testimony of others in its favor, I should, when treating a case
of this nature, insist on its exhibition, at least during the process
of version, and until the hips of the child had been brought into
the pelvis so as to check a farther flow of the blood.

Chioroform, in its secondary action, in a slight degree resembles
the action of Gelseminum, and hence the necessity of precaution in
the combined use of these agents. The first action of Chloroform is
that of a stimulant, mainly on the mental organs, which it excites
and then leads astray. And its later or sedative effect being
mainly spent upon the nerves of sensation, and not of muscular
motion, renders it admisssible to give it and the Gelseminum in
conjunction; out inasmuch as Chloroform does depress the muscu-
lar power of the heart, the above caution in regard to the combi-
nation of it with Gelseminum is deemed necessary.

The presence of the hand and arm, while they occupy the pelvic
canal, press upon the open mouths of the ruptured vessels and
prevent any serious hemorrhage ; and when the body of the child
is in the same position, it answers the same desirable purposeyso
that time can be allowed for the uterus to contract.

Some authors have proposed to push the hand directly through
the placenta, but this proceeding is objectionable from three causes.
1st, By this means many of the larger bloodvessels of the placenta
must be ruptured, thereby greatly augmenting the hemorrhage;
2d, The hand would be likely to pass into the cavity of the mem-
branes at its lowest point, and thus givefree exit to the waters,
which it is desirable to retain, as the child can be more readily
turned when floating in them ; and 3dly, The ruptured placenta may
surround the child on its descent into the pelvic canal, and lessening
its caliber, may greatly retard the exit of the hips, shoulder, or
head.

Others have proposed that the placenta be entirely separated
from its attachments and removed ; but this can not occur without
an exit of the waters, thus embarrassing the passage of the child;
and also, if the placenta be detached, there is great liability of the
child's death from the free discharge of blood from the placenta,
and the consequent drain of the vital fluid from the system of the
fetus.

Sometimes the placenta will be expelled before the physician has
arrived, or before he has had time to pass it to one side; and then

COMPLICATED LABOR — PLACENTA PRJEVIA.

477

the danger of death to the child is imminent indeed : perhaps, by
promptly ligatiug the umbilical cord, it may yet be saved from
fatal hemorrhage.

It has been proposed to place the expelled placenta in a ewer of
warm water ; but what the eminent men who propose this method
of procedure expect from its adoption, does not appear very dis-
tinctly. The warm water can not be sucked up by the umbilical
cord to enter the fetal circulation, but the warmth and moisture
can, and will make the loss of blood more profuse, and conse-
quently increase the danger.

The detachment and expulsion of the placenta, especially if it
also be quickly followed by the fetus, is attended with great dan-
ger to the mother, from the sudden shock the system receives
when debilitated by the profuse loss of blood.

We are all aware that the sudden evacuation of a large quantity
of water in ascites, is almost certain to be followed by alarming
syncope ; and the same conditions which produce the fain tings
after tapping, are present when the gravid uterus is suddenly
emptied of its contents. Hence, the elder and the younger Raras-
botham have recommended that in these cases great care should
be taken not to entirely empty the uterus too rapidly. In addition
to this, I would also advise that a properly adjusted bandage be
so applied that it may readily be made to press upon the abdomi-
nal walls, and thus prevent the syncope, and even the internal
hemorrhage which might be present, were these precautious
omitted.

As stimulants will be indicated by the great prostration of the
system, the friends of the patient may wish to ply her with alco-
holic drinks in some form. This must be most strenuously forbid-
den, for all the inebriants tend to liquefy the blood, to excite the
system, and after the stimulating stage has passed, to produce
great physical and mental prostration.

Ammonia, especially the carbonate, may be freely given, along
with an infusion of Cinnamon, or a very small amount of the
essence of Cinnamon ; and the woman must be kept quiet and cool,
with the hips and extremities elevated, and the head and chest
depressed, and in time she will rally so as to be past danger ; but
if inebriants be allowed, although they may at first appear to exalt
the vital powers, this exaltation will be fleeting, illusive, and be
soon followed by still greater and more dangerous prostration."

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AMERICAN ECLECTIC OBSTETRICS.

CHAPTER XXXVII.

COMPLICATED LABOR. ACCIDENTAL HEMORRHAGE CONCEALED HEMORRHAGE HEMOR-
RHAGE AFTER PLACENTAL DELIVERY EFFECTS OF LOSS OF BLOOD.

The SECOND FORM of puerperal hemorrhage is that which
occurs in the latter weeks of pregnancy, as well as during labor, in
which the placenta is not attached to the inner os uteri, but to
some other portion of the uterine parietes. It includes hemor-
rhages at any stage of labor previous to the birth of the child ; as,
before the rupture of the membranes, after the evacuation of the
amniotic fluid, after the expulsion of the head, and during the
presence of the shoulders in the pelvic cavity. It has been termed
accidental or concealed hemorrhage.

The immediate cause of this kind of hemorrhage is the separa-
tion of a part or the whole of the placenta from the uterus, and
which may be the result of severe or sudden shocks, as blows, falls,
undue pressure over the hypogastrium, mental agitation, excessive
laughter, straining at stool, etc. ; more commonly, it is owing to
some internal cause, as shortness of the umbilical cord from sur-
rounding the child's neck or body, abnormal condition of the pla-
centa, etc. Occasionally it takes place without any discoverable
cause.

More commonly, accidental hemorrhage is not observed until
after the commencement of labor ; but it frequently happens that
there may be one or more discharges of blood for some weeks pre-
viously. These early discharges may determine the character of
the difficulty, and its disconnection with placenta pnevia, by
observing that, in almost all instances they have been preceded
by some sudden or unusual shock, while in placental presentation,
the flooding occurs suddenly without any previous excitement or
injury, and frequently happens during sleep.

The hemorrhage may immediately manifest itself upon the
presence of the exciting cause, or it may not appear for a greater
or less time subsequently, being preceded by uneasy sensations,
and an aching and dull pain in the back and abdomen. Its quan-
tity may vary from a few ounces to an amount sufficient to speedily
destroy life, being generally proportioned to the extent of surface
exposed ; but, very frequently, fatal flooding occurs where the
exposed space scarcely exceeds an inch square. And it may, or
may not, be accompanied by labor-pains, depending, however,

COMPLICATED LABOR — CONCEALED HEMORRHAGE, ETC.

479

upon the period of gestation when it happens; but should this be
at full terra, and the pains present, the hemorrhage will be checked
while they are on, but will return again during the intervals
between them.

It must be recollected that, there may be a very ssrious hemor-
rhage going on internally, without the appearance of a single drop
of blood externally, and if the practitioner is not aware of this fact
he may lose his patient, even before he suspects the true state of
her case. Therefore, we are never to judge of the condition of the
patient by the amount of blood which has been discharged exter-
nally— and this rule will hold good in all puerperal hemorrhages —
but, by the general symptoms of exhaustion, as rigors, weight or
sudden distension of the uterus, faintness, nausea, vomiting, cold -
ness of the extremities, feeble but rapid pulse, hurried breathing,
paleness of countenance, sighing and yawning, and, if the discharge
be not arrested, intolerable restlessness, dimness of sight, ringing
in the ears, hiccough, and death preceded by syncope or convul-
sions; and these symptoms may be present when the vaginal dis-
charge is so slight as hardly to attract any notice. Usually, when
syncope occurs, it is followed by a suspension of the hemorrhage,
which reappears as often as the patient becomes conscious, and
thus syncope and hemorrhage may continue to alternate with each
other, until the fatal moment arrives.

DIAGNOSIS. — In all cases of puerperal hemorrhage occurring
previous to the birth of the child, it is an imperative duty on the
part of the medical attendant to institute a careful examination
per vaginam, in order to ascertain whether or not the placenta be
completely or partially over the inner os uteri. Of course, if the
hemorrhage should be present previous to the commencement of
labor, the os uteri will be found undilated, and no information can
be had by the examination. If, however, it happens at term, and
especially if pains are, or have been recognized, the cervix will be
found relaxed and yielding, a result caused by the hemorrhage,
and we can usually introduce the finger within the os uteri so as
to detect either the membranes or the placenta. In the flooding
under consideration, the finger will not find the placenta at any
part of the os internum uteri; this latter will be free, its marginal
circumference will be of the same thickness all round, and the
membranes only will be felt in contact with the point of the finger
when this is advanced upward.

Beside this investigation, which should, as before remarked,

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AMERICAN ECLECTIC OBSTETRICS.

always be made, there are several signs which will materially assist
in the diagnosis. Thus, in accidental hemorrhage, some previous
excitement or shock will generally have occurred ; if the pains are
on, the hemorrhage is arrested by them, but recurs during the
intervals — in /unavoidable hemorrhage the discharge continues
during the intervals, and is augmented by the pains.

TREATMENT. — The treatment of accidental hemorrhage will
vary according to the quantity of blood lost, the period, at which
it occurs, and the condition of the os uteri. When it occurs pre-
vious to full term, labor-pains being absent, and no tendency to
dilatation on the part of the os uteri, the hemorrhage not being so
profuse as to impair the constitutional powers, we should endeavor
by all means to stop it, and prevent if possible, its return.

The patient should be kept in a horizontal position, on a cool,
hard bed ; her covering should be light, and the surrounding tem-
perature of the room should be considerably reduced. Cold water
only should be allowed, or ice ; or the water may be acidulated
with mineral acids, which exert no injurious influence and are
usually acceptable. Injections of cold water, and cold applications
over the external organs will frequently prove advantageous, but
these should not be used when the system has become excessively
depressed. The plug or tampon, is advised by some writers, but
I consider its use contra-indicated, from the fact that an external
flooding may be changed into an internal one. The patient must
not be allowed to get up for any purpose whatever, and in the
alvine evacuations, especially to lessen straining efforts, it will be
better to aid by rectal enemata.

Should the flooding be very excessive, some of the means here-
after named, under the treatment of hemorrhage after the delivery
of the placenta, may be emplo}Ted, as, ligating the limbs, tincture
of Cinnamon, or its combinations, oil of Erigeron, etc.

When, notwithstanding all our efforts to check the discharge, it
still continues, we can not expect that pregnancy will persist to
the full period, and the only course that can be pursued to perma-
nently arrest the hemorrhage and lessen the dangers to the female,
will be to effect an evacuation of the uterine contents. The palli-
ative measures will now be of no avail.

The proper course, then, will be to rupture the membranes, and
favor the escape of the amniotic liquor, by holding up the child's
head ; the contractions of the uterus may be excited by the appli-
cation of the bandage, by gentle pressure made around the os uteri

COMPLICATED LABOR — CONCEALED HEMORRHAGE, ETC. 481

with one or two fingers, and ergot and stimulants may be advan-
tageously exhibited. In these cases, the os uteri will most com-
monly be found soft and dilatable, but should it be rigid and
undilated, the rapturing of the membranes should not be attempted
until this condition is overcome, and which may be readily accom-
plished by the tincture of Gelseminum, tincture of Lobelia, or
other means heretofore explained.

The discharge of the waters, and the employment of the
measures named, will, in the majority of cases, cause the uterus to
contract and speedily evacuate its contents, and which action is
almost invariably accompanied with a cessation of the hemorrhage.
True, the life of the child may be endangered, but this is never to
be taken into account when the mother's life is at stake.

I am aware that several writers have objected to rupturing the
membranes in these instances of flooding, but their objections
appear to me very insufficient, and the testimony of many eminent
accoucheurs, together with my own experience, justifies me in
strongly recommending this method, instead of immediate delivery
by turning; the hand should in no case be passed into the uterine
cavity, unless the safety of the female imperatively demands it; and
it must be borne in mind, that in cases of uterine hemorrhage,
where the membranes are felt at the mouth of the uterus, turning
is very seldom required, though it is always necessary in complete
placental presentation. Sometimes, after the membranes have
been ruptured and the above means used to arouse uterine action,
nothing will be accomplished, the hemorrhage will continue, and
the treatment will fail to bring about the desired contractions;
this, however, is not apt to occur, unless the attendant has too long
delayed the operation, or, where the whole or nearly the whole of
the placenta has become detached, and an excessive internal
hemorrhage has consequently ensued. In these cases of failure it
will become necessary to effect the delivery by turning, the
employment of the forceps, or the perforator, as the exigencies of
the case may demand. "When a preternatural presentation is
ascertained in these cases of hemorrhage, it then always becomes
necessary to effect a version as speedily as possible, but not before
the os uteri is in a proper state, leaving the subsequent delivery to
the natural powers when these are efficient. When the hemor-
rhage has occasioned great exhaustion of the system with syncope,
the discharge being suspended, as heretofore observed, the practi-

482

AMERICAN ECLECTIC OBSTETRICS.

tioner must be extremely cautious how he attempts, or proceeds in
his manual operations.

Should there be any delay in the delivery of the placenta, it is
generally better, in cases where the hemorrhage has been profuse,
to extract it, in order to secure permanent contraction of the
uterus and thereby lessen any tendency to a continuation of the
flow, and every means and care must be employed to guard, not
only against a return of the flooding, but also against an attack of
inflammation. After the delivery, the female should be managed
as hereafter advised.

The THIRD DIVISION" of puerperal uterine hemorrhage,
is that which occurs after the delivery of the child, but before the
expulsion of the placenta; it is frequently met with in practice,
and usually comes on suddenly and in excessive quantity, greatly
alarming the patient and her friends. The cause of this flooding
is, as in the previous ones, a more or less complete detachment of the
placenta from the uterine walls, with inertia or inefficient action of
the uterus. It may occur in instances where previous pains were
feeble and with long intervals, as well as in cases where the labor
had thus far been prompt and energetic; and it is frequently mani-
fested even when the preceding stages of labor had been most
prudently and skillfully managed. The recommendation, hereto-
fore given, that after the birth of the child the accoucheur should
ascertain whether the uterus is contracted or not, by placing his
hand upon the abdomen of his patient and feeling through its
parietes for that organ, is one which should never be admitted, a
rigid observance of this rule will keep him thoroughly informed
as to the condition of the gestating organ, so that he can always
be ready for prompt measures whenever required.

In these instances of hemorrhage, shortly after the birth of the
child, or, perhaps, immediately succeeding it, a profuse quantity of
blood is suddenly and rapidly discharged, and the first indications
which the practitioner receives of the danger, are the pallid coun-
tenance, and the rapid and feeble pulse of his patient, with
syncope, or a state approaching to it. On placing his hand upon
the abdomen, the womb will be felt soft and flabby, and perhaps,
somewhat enlarged; in a state of contraction it always offers
a firm, hard resistance when pressed upon. The female soon
becomes utterly unconscious, even before complete syncope has
ensued, being unable either to see or hear anything around her,

COMPLICATED LABOR — CONCEALED HEMORRHAGE, ETC.

483

and if relief be not promptly given, the hemorrhage will speedily
prove fatal.

TREATMENT.— In all cases of hemorrhage previous to the
delivery of the placenta, there is but one course to 'pursue, and
that is, to artificially separate and remove the placenta, and "no
man is thoroughly prepared to undertake the charge of a common
midwifery case, who would hesitate to pass his hand into the
uterus and remove the placenta, whether adherent or detached,"
in a dangerous flooding of this character; and in my opinion, the
sooner this operation is attempted, the greater is the security
afforded to the woman; do not wait for the hemorrhage to become
profuse and exhausting before interfering.

The suddenness and profuseness of the discharge may at first
startle the young accoucheur — but he should not hesitate, and
tamper with the case by endeavoring to extract the placenta with
pulling up on the cord, because, he may invert the uterus, or else
break the cord off in the neighborhood of the after-birth, in either
case,,increasing the danger. Neither should he attempt to overcome
the hemorrhage by internal or external means alone — leaving the
introduction of the hand as a dernier resort — because, in these cases,
a few minutes are of immense value to the patient — and such delays
are trifling with her life. If the practitioner becomes excessively
alarmed, or loses his presence of mind, and feels a hesitancy as to
the course he should pursue, he should not attempt interference
lest he might increase the hazards, but should at once send for
counsel.

On the manifestation of the hemorrhage, he will immediately
place a bandage around his patient's abdomen with a compress
beneath it to make pressure upon the uterine fundus, and will have
the whole firmly secured. Then removing his coat, and rolling up
his sleeves, he will gently stretch the cord with his left hand, and
following it as a guide, conduct his right hand to the placenta; if
on entering the os uteri, this be found contracted, it may be suffi-
ciently dilated as the fingers and hand pass through it. Upon
reaching the placenta, the fingers should be extended to its circum-
ference, and its adhering portion slowly and cautiously detached,
being careful that the separation is complete before attempting its
removal from the uterine cavity. After the placenta has been
reached, the other hand should be placed externally upon the
abdomen of the patient to support and steady the uterus, other-
wise, it will be very apt to move about, and retard the operation.

484

AMERICAN ECLECTIC OBSTETRICS.

The operator must bear in mind that by following the cord he will
reach the fetal surface of the placenta — and should he become
embarrassed by the membranes in his search for its periphery, the
hand should be withdrawn to the cervix, placed against the uter-
ine walls, and I he fingers carefully passed along the placenta.

In separating the placenta from the uterus, the fingers must not
be passed rudely or carelessly between the adhering surfaces, lest
some portion of the uterine surface be injured by the nails, or
otherwise ; neither should the practitioner seize the free part of the
placenta and draw it away, lest some of the unseparated placenta
be torn off and left behind to continue the hemorrhage and render
it fatal, or, at all events to decompose and ultimately to give rise
to the usual symptoms of putrefactive absorption. But, he
should press upon the placenta at its attached points, with the ends
of his fingers, carefully pushing or pressing it off, as though he
were removing the peel from a thin orange, without disturbing the
inner tunic of the fruit or causing any of its juice to exude.

The placenta being detached, the uterus will commonly contract
and expel it and the hand together; or the means heretofore
advised for causing contractions may be employed — and after the
expulsion, contractions occurring, the hemorrhage will cease. How-
ever, should it still continue, it must be treated the same as flooding
occurring after placental delivery.

The removal of the placenta is not, as a general thing, a difficult
operation ; sometimes, however, it may form a partial or complete
morbid adhesion to the uterine parietes, when it must be detached
according to the mode explained when treating of morbid placental
adhesion. In all cases, after having removed the placenta, it
should be carefully examined to ascertain whether any portion of
it is left within the uterus, and if any considerable part of it be
wanting, say, one-fourth, or one-third, the hand should be immedi-
ately re-introduced, to remove the disrupted part, provided the
uterus has not in the meantime contracted around it.

It may be necessary to again advert to a rule which should not
be disregarded; which is, that if the hemorrhage has been very
great, causing excessive debility and syncope, an attempt at
removing the placenta must not be made until the patient rallies
a little ; for if, during the state of syncope the flooding ceases, the
introduction of the hand, by removing the clot formed, would
cause a return of the discharge followed by almost certain death.

In this, as in all puerperal floodings, the patient must not be left

COMPLICATED LABOR — HEMORRHAGE AFTER DELIVERY. 485

too soon, the medical attendant should remain with her an hour
or two after the arrest of the discharge, for the purpose of know-
ing that the contraction of the uterus is permanent, and that there „
will be but little danger of a return of the flow; and on leaving
the house, he should, previously, give full instructions to the nurse,
or some friend, how to proceed, in case of a return of the flooding.
Measures should also be adopted to guard against an attack of
inflammation.

The FOURTH VARIETY of uterine hemorrhage, is that which
appears after the extrusion of the secundines ; this may be exter-
nal and apparent, or it may be internal and concealed. It is an
extremely dangerous form of flooding, often manifests itself sud-
denly and unexpectedly, and is frequently very difficult to subdue.
It is commonly owing to inertia, or want of contractions of the ute-
rus, or perhaps the contractions, may be irregular and unequal ;
occasionally, it may be the result of rupture of the cervix, and will
be severe and dangerous, in proportion to the extent of the rupture-
A certain quantity of blood always escapes from the mouths of the
uterine vessels, after delivery, without causing any alarming or
serious consequences, especially, when the uterine tumor is found
hard and firmly contracted; but when the system experiences the
effects of the loss of blood, and the uterus is found soft, flabby,
and uncontracted, the patient becomes exposed to great hazard.
Among the causes which may induce inertia of the uterus, may be
named, mental excitement, debility of the muscular fibers of the
uterus after a labor aided by Ergot, high temperature of the room,
reaction from the use of stimulants, a clot filling up the os uteri, con-
stitutional or local incapability of muscular contraction, neglect of
the bandage, meddlesome interference, etc.

The hemorrhage may come on immediately after the expulsion
of the secundines, even when the labor has been thus far favorable
and without any Untoward accidents; or, it may not appear for
half an hour, or an hour after the delivery ; and, sometimes, sev-
eral hours or even days may intervene before the effusion is mani-
fested. Usually, after the first gush of blood, the patient faints,
and the discharge becomes lessened or suspended; she rallies, the
effusion returns, is again succeeded by fainting and a suspension
of the flow, and in this manner the rallying, flooding, and fainting
alternate, until the system has become so exhausted that reaction
is impossible, and death terminates the scene. Sometimes, the

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AMERICAN ECLECTIC OBSTETRICS.

discharge will take place slowly, continuing for some time before
the patient becomes completely lost in a fatal syncope. Again, the
first gush is, occasionally, so great as to produce excessive prostra-
tion of the system, with syncope, from which the patient never
rallies. The influence of the discharge upon the system, varies
with different women ; some may have but an inconsiderable
degree of depression from an excessive flow, while others will be
destroyed by the loss of from twelve to eighteen ounces. And the
hemorrhage is not to be dreaded, therefore, so much from its quan-
tity, as from its effects upon the constitution.

SYMPTOMS. — This form of hemorrhage usually comes on sud-
denly, presenting the symptoms common to copious effusions of
blood. Generally, the first intimation the physician has of the
danger, is an expression from the patient of excessive faintness :
her countenance becomes pale, the breathing difficult and hurried,
the extremities cold, with a cold perspiration on the face and fore-
head, and the pulse rapidly becomes small, quick, feeble, fluttering,
indistinct, and perhaps entirely suspended for a few beats, accom-
panied with a state of unconsciousness, which often comes on in
a few seconds. On examining the bed and napkins, a large quan-
tity of blood will be found, perhaps so excessive as to find its way
from the bed to the floor; or there may be a very small discharge
externally, but a copious one internally.

If the first gush should not prove fatal, after a greater or less
duration of the syncope, the pulse returns, gradually increasing in
strength, the countenance becomes a little more florid, the extrem-
ities warmer, the breathing more natural, and the patient recovers
her consciousness. If the system has been considerably depressed
by the discharge, she now manifests much restlessness and uneasi-
ness, throwing her arms about, gasping and crying for fresh air,
to be fanned, etc., with anxious expressions and apprehensions of
dying.

After the first rally, in a short time she sinks again under
a return of the hemorrhage, from which she may again recover,
and so alternate for several times in succession, until finally she
complains of a tightness of the chest, a sense of suffocation, which
may be followed by a few spasmodic struggles or convulsions, ter-
minating in death. The fluttering, indistinct pulse, the pallid
counteuance, the hurried respiration, the intolerable restlessness,
with rigors and vomiting, are indications of excessive depression
of the physical powers, requiring prompt, energetic, and decisive

COMPLICATED LABOR — HEMORRHAGE AFTER DELIVERY. 487

measures, which must be perseveringly persisted in until the
patient either recovers, or sinks beyond mortal aid.

The hand being placed upon the abdomen, will, in case of inter-
nal hemorrhage, find the uterus soft and fluctuating, and of a size
nearly equaling that previous to the delivery ; and if pressure be
made upon it, a gurgling sound will be heard, accompanied with
a gush of blood, fluid or coagulated, from the vulva. When the
flooding is external, an examination of the bed and napkins will
give some idea of the copiousness of the discharge ; and although
the uterus will be found soft and flabby, it will not be so large as
in the former case.

In these hemorrhages after delivery, the accoucheur should
always ascertain two things : first, that the whole of the placenta
has been abstracted, for a small portion retained within the uterus
has frequently given rise to copious flooding ; and when called in
to a case as consulting or assisting physician, he should never for-
get to ask for the placenta, that he may examine it carefully : this
should never be omitted, even though the attending physician
should insist that it had been completely removed; for cases have
occurred in which such assertions have been found erroneous — not
intentionally, but from an insufficient or hasty attention to the
matter. Secondly, ascertain that the uterus is not inverted, a con-
dition which may be readily effected by traction upon the cord, or
drawing down of the placenta, when the organ is in a relaxed and
paralyzed condition; and the^mode of ascertaining this will be
explained under the head of Inverted Uterus.

TREATMENT.— The flooding which occurs at the parturient
period is not owing to any increased or inordinate action of the
heart and arteries, and is, therefore, a passive hemorrhage, being
caused solely by the exposure and patulous condition of the
orifices of the uterine bloodvessels, the result of placental separa-
tion and non-contraction of the uterus. The indications of treat-
ment are, to arouse the contractions of the uterus, by which alone
can we expect to suppress or check the hemorrhage, and to sup-
port the strength of the patient.

If, upon examination, it be ascertained that a considerable por-
tion of the placenta has been left within the uterine cavity, the
hand must be immediately introduced, as heretofore stated, lor the
purpose of removing it; and, usually, the uterus will contract
as soon as the removal is effected, thereby arresting any further
flooding.

488

AMERICAN ECLECTIC OBSTETRICS.

But the placenta may have been entirely removed, and still a
profuse hemorrhage be present: the womairs safety, then, depends
entirely upon the induction of uterine contraction. The practi-
tioner must proceed calmly, steadily, and energetical ly : a hesita-
tion, a falter, a timidity, and above all, an inexcusable ignorance
of his duties, are almost certain death to his patient. Everything
around is calculated to unman him, if he has not previously
instructed and prepared himself ; the appalling discharge of blood —
the sudden pallor of countenance, depression of pulse, and loss
of consciousness — the intolerable and significant restlessness,
gaspings for air, and heart-rending exclamations of anticipated
death — together with the alarm, the agonizing anxiety, and
hurried whisperings and questionings of friends, are but little
conducive to assist him in tranquilizing his mind. But notwith-
standing all these, he must be composed, positive, prompt, and firm
— must subdue all his own feelings, for the safety of his patient;
and without he is able to do all these, he is unfit for the responsi-
ble duties of an accoucheur.

The hand of the practitioner must be placed upon the abdomen
of his patient, for the purpose of making firm and constant
pressure over the fundus uteri, and the pressure may require to be
continued for two or three hours, in which case an assistant may
relieve the medical attendant by performing this manipulation,
and which will always be found superior to a bandage: not only
should the fundus be compressed, but it should be grasped,
squeezed, or kneaded by the hand, which will tend to arouse its
contractions, as well as to prevent it from becoming filled and
distended with blood and clots; and this should be continued, not-
withstanding the patient may desire us to desist on account of the
pain produced. The pressure or kneadings should never be so
powerful as to indent, or cause a partial or complete inversion of
the uterus. When the flooding has been arrested, a bandage and
compress over the fundus may then be substituted. In conjunction
with the pressure, cold applications should be applied to the pelvis;
thus, cold water, or a mixture of cold water and vinegar should
be poured upon the naked abdomen from a considerable bight;
and napkins may be dipped in the same, and then applied suddenly
to the- vulva, the thighs and nates. And this treatment should be
persevered in until the shock or succession of shocks arouses
uterine action. Ligatures should be applied around the thighs,
in all cases, as early as possible. When the system becomes con-

COMPLICATED LABOR — HEMORRHAGE AFTER DELIVERY. 489

siderably depressed, some care will be required in the resort to the
above cold applications, as their constant use, at this time, will be
apt to cause injurious rather than beneficial results.

Injections of Cold Water into the vagina, uterus, and rectum,
have been advised, but I have never employed them: should I
deem such means requisite at any time, I think I would prefer
injecting a cold solution of Borax into the rectum, on account of
its well-known influence on the contractile powers of the uterus,
even when used in this manner.

Internally, Ergot is indicated, but it will frequently fail in effect-
ing an}7 beneficial result. I place great confidence in the exhibi-
tion of tincture of Cinnamon, which undoubtedly exerts an
influence upon the uterus : it may be given in teaspoonful doses,
in'some sweetened water, and repeated every ten, thirty, or sixty
minutes, according to the urgency of the case; or it may be bene-
ficially combined with other agents, thus : Take of tincture of Cin-
namon, tincture of Ehatany, oil of Turpentine, each, equal parts :
mix together, and give from half a fluidrachm to a fluidrachm for a
dose, in some convenient vehicle, and repeat as may be required.
Or it may be combined with Tannic Acid, tincture of Ergot, and
Port Wine; or with tincture of Catechu, oil of Erigeron, or oil of
Senecio Hieracifolius. But it must be recollected, that however
valuable they may be in other cases, astringents are of but little
value in these floodings, unless the contraction of the uterus is
effected, and then they are not required. It is only in instances of
moderate flooding where these agents are apparently beneficial.

The tincture of the fresh inner bark of the Cotton root, pre-
pared with the spirit of Nitric Ether, has been found, in the prac-
tice of several practitioners, as well as in my own, very successful
in menorrhagia, almost amounting to a specific; and this fact, in
connection with a knowledge of its abortive action, has led me to
try the following mixture in a few recent cases of uterine hemor-
rhage, and apparently with most decided success: Take of the
tincture of inner bark of Cotton root, tincture of Ergot, and
tincture of Cinnamon, each, equal parts: mix together. Dose,
from half a fluidrachm to a fluidrachm, in Port Wine, or other
convenient vehicle, as often as required.

The Calcined Deer's Horn (See American Dispensatory, page
350), has been highly recommended in uterine hemorrhage, having
always succeeded in arresting the discharge, when other means
have failed. I have not employed it in practice, having succeeded
32

490

AMERICAN ECLECTIC OBSTERICS.

in these cases by the means above described. Yet its positive
influence in checking hemorrhage has been frequently named to
me, by physicians who have used it, and whose statements are
entitled to confidence ; beside, I know of instances where it has
been exhibited with success. It is generally administered in
drachm doses, repeated every ten, twenty, or thirty minutes ; each
dose may be added to about a gill of hot water. This preparation
is considered a powerful styptic, from the facility with which
hemorrhages are checked by its internal use ; yet, from its benefi-
cial results in menorrhagia and uterine hemorrhage, it must
undoubtedly exert a decided influence upon the uterus itself, inde-
pendent of any styptic power it may possess. It would be well for
practitioners to ascertain whether it possesses any power over the
contractility of the muscular fibers of the uterus, in instances where
the pains of labor are weak or inefficient. Equal parts of calcined
Deer's Horn, compound powder of Ipecacuanha, and Opium, and
Capsicum, mixed together, is a common preparation with many
physicians in uterine hemorrhage of moderate severity, the dose
being from five to ten grains, as often as circumstances indicate ;
and many are in the habit of giving a dose immediately after the
birth of the placenta, supposing that it prevents a tendency to
flooding.

Other agents have been advised, but I am not acquainted with
any especial value they possess, for instance — a mixture of three
parts of Alum, two of Capsicum, and one of Geranium, in dose3 of
twenty grains every ten, twenty, or thirty minutes. Likewise,
doses of Tannic Acid five grains mixed with half a grain or a grain
of Opium, and repeated according to indications. It makes, how-
ever, but little matter what remedies be used, so that the most
important indication be fulfilled — energetic and permanent uterine
contractions.

Prof. Meigs recommends the following course, in obstinate cases :
" If the student should find the hemorrhage not to be stayed by
his treatment, let him press his fingers, gathered into a cone, firmly
down upon the aorta, near the umbilicus. If the patient should
not be troubled with extraordinary obesity, he will be able to feel
the throb of the aorta with the points of the fingers. Let him
compress the tube according to his judgment, in such a way as to
check the downward rush of the torrent. This will operate use-
fully in two ways — first, by lessening the force with which the
blood reaches the bleeding orifices, which will then have an oppor-

COMPLICATED LABOR — HEMORRHAGE AFTER DELIVERY. 491

tunity to close themselves, more or less completely ; and second,
by causing a greater determination of blood to the encephalon,
whereby the tendency to deliquium will be lessened. Many lives
have apparently been saved by thus compressing the aorta." I
have never tested this method, having generally succeeded in
checking the hemorrhage by the means above named, yet I have
no doubt of its efficacy in many cases, and can bring to mind
instances in which it might have been the means of saving several
valuable lives ; however, I should not hesitate to adopt it when
other means proved ineffectual, and would favorably recommend
it to the attention of the student. Baudelocque, I think, advised
a somewhat similar course.

The introduction of the hand within the uterine cavity, in
hemorrhage after the delivery of the placenta, for the purpose of
stimulating the uterus to act, by making pressure and frictions
upon its inner walls, should never be attempted ; but, it may fre-
quently be necessary to introduce it for the removal of the coagula,
which sometimes adhere so strongly to the inner uterine membrane
as to oppose all natural efforts at expulsion, and by their presence,
keep up a greater or less amount of flooding, even though contrac-
tions may have been induced. On this point, however, there is
much diversity of opinion.

The coagulum formed within the uterine cavity, may usually
be considered a means adopted by nature to check the flooding,
as well as to eventually stimulate the organ to contraction. In
many instances, the introduction of the hand, with frictions inter-
nally and externally, and aided by Ergot, fail to arouse the activity
of the uterus ; it continues soft and flabby, and if the coagula are
removed with the womb in this inert condition, it may be followed
by a fatal increase of the hemorrhage. The safety of the woman,
in such case, depends entirely upon the presence of the coagula,
and its continuance until contractions are excited, when they will,
as a general rule, be expelled without artificial aid. Again : should
the uterus be suddenly aroused, as has been the case, and contract
upon the hand within its cavity, the position of the accoucheur,
as well as of his patient, will be, at least for a time, anything but
agreeable — the hand being fastened within a firmly contracted
womb. An artificial removal of the clots may, however, be advisa-
ble where there has been a failure of the other means employed,
with considerable distension of the uterus, and symptoms indica-
tive of a flow internally ; here, the removal of the coagula, fol-

492

AMERICAN ECLECTIC OBSTETRICS.

lowed by active means to secure uterine contraction, may prove
serviceable, but it should be undertaken with cautiousness and
prudence, because, if we fail to induce the desired contractions,
the consequences to the patient become more serious. A removal
of the coagula may likewise be attempted in cases where the uterus
is small, with contractions or a disposition to become firm, but
where, notwithstanding, the flow of blood continues in great quan-
tity : in these cases the clots are usually so firmly agglutinated to
the inner walls of the uterus, that the efforts of the organ can not 1
expel them. Any great accumulation of coagula, however, will
not be apt to take place, if strong pressure or kneading be applied
over the fundus uteri by the hand, or by a properly adjusted com-
press and bandage : it is the neglect of this measure which fre-
quent^ occasions the difficult};*. When the external hemorrhage
has not been great, but the constitutional symptoms indicate a loss
of much blood, and there is but little distension of the uterus, an
examination may find the vagina filled with a coagulum, and this
should be at once removed.

Dr. Rigby speaks favorably of applying the child to the mother's
breast, in this variety of flooding; suckling frequently induces
after-pains, and from the sympathy existing between the uterus and
mammae, it may be found an efficacious method of causing the
uterus to contract : if the plan be tried, the mother should not be
moved or disturbed in her position. Galvanism has been recom-
mended by Dr. Radford, and there is no doubt but it will prove
successful in many instances.

An important point, to which I have heretofore adverted, is not
to interfere when syncope is present. Any depression of vascular
action is favorable to coagulation of the blood, and we most com-
monly find a cessation of the discharge while the patient lies in
this condition ; and an attempt, at this time, to introduce the hand
within the uterus, or inject fluids into its cavity, may, by removing
the clots formed, occasion a fatal renewal of the hemorrhage.
Neither should stimulants be given unless absolutely required,
because the sudden increase in arterial action occasioned by their
exhibition may not only prevent a coagulum from forming, but
may also remove that which has already been deposited over the
orifices of the bleeding vessels — of course, increasing the dangers
of the hemorrhage.

Indeed, stimulants are only to be administered when the system
has become considerably depressed, and when there is reason to fear

COMPLICATED LABOR — AFTER-TREATMENT OF HEMORRHAGE, ETC. 493

vhat the syncope would prove mortal: then the vascular action
must be sustained and the vital energies aroused, as an indispensa-
ble measure. Brandy, rum, ether, ammonia, cordials, etc., may be
given, as heretofore recommended in hemorrhage from placenta
praevia. At this time, it will be extremely improper to continue the
local applications of cold as their influence will be to augment the
depression of the system.

Some writers have advised the employment of the tampon, but it
is bad practice. The danger of giving rise to a concealed hemor-
rhage should always deter us from using the tampon in uterine
hemorrhage occurring, especially at the parturient period, unless,
indeed, we except the instances of placenta praevia referred to on
page 466.

In cases of excessive prostration, transfusion has been advised. I
have no knowledge of its effects from my own experience, but the
recorded instances with which I have become acquainted have not
given me any exalted opinion of it.

THE AFTER-TREATMENT OF HEMORRHAGE requires
some attention ; for although the discharge may be arrested, and
the uterus contracted, yet there may be a return of relaxation of the
uterine muscular fibers, with an accompanying flow ; hence, many
hours may pass before the patient will be entirely free from this
danger. As soon as the flooding has been arrested by the means
employed for that purpose, a bandage should be firmly applied
around the body, so as to secure a steady compression over the
fundus uteri : a thick compress placed between the abdomen and
the bandage, will materially aid in accomplishing the desired object,
viz.: to prevent the occurrence of any relaxation of the uterine
fibers. The bandage should be examined every hour or two, to
ascertain that it has not moved, but remains in its proper situation :
it frequently happens, that when the bandage becomes loosened, or
disturbed from its proper position, there will be a return of the
hemorrhage, and of the relaxed condition of the uterus. The
ligatures which were applied around the thighs may be loosened,
but they should not be removed, at least, until a sufficient time has
elapsed to guarantee the safety of the woman from further hemor-
rhage. Upon no account whatever must she be allowed to move
for some hours, proportioned to the severity of the attack. In a
moderate flow, she may be " put to bed " carefully, and her linen
changed, in the course of five or six hours after its cessation ; but

194

AMERICAN ECLECTIC OBSTETRICS.

in profuse and exhausting attacks, twelve or eighteen hours may
elapse before it will be proper to attempt her removal. Sudden
death has frequently occurred by raising the patient in a sitting
posture, for any purpose ; and even a mere change of position from
one side of the bed to the other, has resulted fatallj\ The practi-
tioner will, therefore, see the absolute necessity for strictly enjoin-
ing a state of quiescence for a sufficient length of time. It is
always better to keep the head somewhat lower than the body. As
it would be imprudent to allow the patient to lie in the damp and
moisture around her for any length of time, means must be adopted
to render her comfortable and dry, without moving her in the least,
or allowing her position to be changed. A blanket, or something
of the sort, may be slowly and carefully insinuated beneath her, in
such a manner as to effect the desired result.

To favor a s'tate of rest, as well as to moderate any irritability of
the system, the compound powder of Ipecacuanha and Opium may
be administered in a dose of eight or ten grains, to which three or
four grains of Capsicum may be added. Or, a powder composed of
Capsicum five grains, Ipecacuanha one grain, Opium half a grain,
may be administered every hour or two, as indicated ; the addition
of Capsicum to these preparations has an undoubted tendency to
prevent a return of the hemorrhage, in a majority of cases. The
apartment in which the female lies should be well ventilated, dark-
ened, and the temperature must not be too elevated. If much
exhaustion is present, cold, nourishing, and easily-digested fluids
may be given at short and regular periods, as gruel, beef-tea, etc.;
and when the prostration is excessive, some stimulant may be added.
Visitors must positively be forbidden : no one is required to be in
the room, save the physician, nurse, and husband. Talking, or
mental excitement, whether pleasurable or not, is very apt tomduceja
return of the flow.

In cases where the hemorrhage has not been profuse, the practi-
tioner should not leave the patient for two or three hours ; but in
the more ^copious and exhausting discharges, the female is not
thoroughly safe until five or six hours have elapsed since their arrest ;
and she should not be left, in these instances, until this period has
passed by. A careful and conscientious accoucheur will never leave
his patient at too early a period, but will remain and watch her
closely. If the pulse be quick, compressible, and jerking, indicative
of hemorrhage, he will be on his guard, and prepared to meet it on
its first appearance.

COMPLICATED LABOR — AFTER-TREATMENT OF HEMORRHAGE, ETC. 495

Where females are liable to attacks of hemorrhage after the
expulsion of the child, or placenta, it may frequently be prevented
by the use of some uterine tonic during the last three or four months
of utero-gestation ; as for instance, the compound syrup of Par-
tridgeberry, Caulophyllin, Aletridin, etc. And at the time of labor,
the os uteri being dilatable, the membranes may be ruptured at an
early period, when the presentation is natural ; and as soon as the
child is born, the bandage and compress over the fundus uteri should
be firmly applied.

In cases of excessive hemorrhage, and after the patient has fully
recovered from the syncope, a 'powerful reaction usually ensues,
accompanied with a greater or less degree of nervous irritability.
The velocity of the circulation becomes increased in proportion to
the decrease which the blood has experienced, its momentum prob-
ably atoning for the deficiency in quantity. Fever is commonly
present when this reaction occurs.

There will be throbbing of the temples, a distressing pain in the
head, vertigo, ringing in the ears, and an intolerance of noise, and
occasionally of light. In nearly every case pain in the head will be
complained of, accompanied with a sensation or noise, which may
be variously compared to the beating of a small hammer within the
skull, the ticking of a clock, the singing of a teakettle, or the roar-
ing of the sea, and which is probably owing to the forcible contrac-
tion of the arteries upon the diminished amount of blood contained
in them, propelling it onward by jerks. The pulse will be quick,
small, jerking, and wiry or compressible; the least motion causes
great disquietude ; there will be a sense of faintness and of impend-
ing dissolution, especially on being raised from the pillow. The
skin becomes hot and dry, the mouth dry and parched, and the fea-
tures are shriveled, with a contracted state of the lips and nose.
Palpitations or flutterings of the heart are often present, as well as
panting, sighing, moaning, dyspnoea, and sometimes a hacking, irri-
tating cough. Fresh air or the smelling-bottle will frequently be
called for. On awaking from sleep, or on being suddenly disturbed,
the patient will exhibit a degree of hurry and alarm. Sometimes
there will be retching, or vomiting, hiccough, and a dislike for solid
food. All the secretions become lessened, the bowels are flatulent,
and constipation or diarrhea may be present. "Wakefulness is not
uncommon. Various organs, as the peritoneum, pleura, or brain,

496

AMERICAN ECLECTIC OBSTETRICS.

may present symptoms of inflammation ; and upon arising or
assuming the erect position, death may suddenly occur.

These symptoms will, of course, vary, both in kind and degree,
in different females, depending on the extent of prostration and
other concomitant circumstances ; but the peculiar pain and noise
in the head will very rarely be absent.

TREATMENT. — The above disagreeable conditions are depend-
ent on a diminution of the quantity of blood in the system, and
the indications will be, to increase the amount of blood, to impart
tone and vigor to, the constitution, and to remove the various
unpleasant symptoms with which the patient is annoyed.

To fulfill the first and second indications, it will be necessary to
allow the patient nutritious and easily-digested articles of diet, as
boiled milk, arrowroot, calf 's-foot jelly, beef, mutton, and chicken
broths, oyster soup, custard, soft boiled eggs, Indian meal gruel,
etc. If required, wine or brandy may be added to the diet, and
even ale or porter is admissible in some cases; but all stimuli
should be allowed with much caution. The nourishment
should be given at regular periods, and in small quantities, so as
not to oppress or offend the stomach.

For the removal of annoying symptoms several means may be
required. Thus, the heat and dryness of the surface may be
relieved by sponging the head, body, and limbs with cold or tepid
water, or vinegar as circumstances will indicate: the compound
powder of Ipecacuanha and Opium will likewise assist in the
accomplishment of this result, as well as to allay nervous irrita-
bility and relieve the distress in the head; and the patient should
be kept in a cool and well-ventilated room, and in a state of per-
fect quiet and rest. "Where Opium or its salts of Morphia disagree,
other agents may be advantageously exhibited, as Hyoscyamus,
Scutellarin, or infusions of Cypripedium, Ictodes, Scutellaria, etc.
A pill composed of equal parts of Scutellarin, Lupulin, and
Cypripedin, will be found beneficial: it may be made into three-
grain pills, and one or two administered every hour or two. The
tinctures of Hyoscyamus and Aconite-root will frequently afford
much relief in allaying pain and nervous irritation. As little
medicine as possible should be employed in these cases; the
greatest reliance must be placed upon fresh air, quiet, and nourish-
ment.

Constipation may be treated by Seidlitz powders; by the mix-
ture of Rhubarb two parts, and Bicarbonate of Potassa one part,

COMPLICATED LABOR — AFTER-TREATMENT OF HEMORRHAGE, ETC. 497

heretofore referred to on page 145; or by rectal injections. But
in all instances active medication of any kind must be positively
avoided. The distress in the head, quick pulse, fever, constipa-
tion, etc., may lead the young accoucheur to suppose that relief
will be obtained by an active purge, which, if administered, may
prove injurious to his patient. The difficulty, as before remarked,
is due to the loss of blood, and not to any determination of this
fluid to the brain or other organ; and so soon as the bloodvessels
become filled with the necessary amount of their proper fluid, all
the symptoms will disappear. However, should the face, instead
of the usual pale appearance, become tumid and slightly florid,
from an excess of blood in the veins, warm applications may be
applied to the feet and limbs, with cold to the face and head, for
the purpose of equalizing the circulation.

The patient must not be allowed to get up, for any purpose
whatever, until all the above-described symptoms have disap-
peared; and when this is attempted, care must be taken that it be
effected slowly, and that at first the sittings be for a very short
period only. And should the sitting posture occasion a sensation
of faintness, it must be dispensed with, and not tried again for a
few days. Too much attention can not be paid to this point.

CHAPTER XXXVIII.

COMPLICATED LABOR RETENTION OF THE PLACENTA POUR-GLASS CONTRACTION MORBID

ADHESION OF THE PLACENTA FUTREFACTITE ABSORPTION.

In primiparse, the placenta, in the greater number of instances,
immediately follows the expulsion of the child, and with others it
usually comes away in from five to twenty minutes thereafter; but
cases frequently occur in which it remains for hours, or even days,
if permitted, before it will pass off; and whenever it is not
expelled within an hour after the birth of the child, it is called a
retained placenta.

Young accoucheurs frequently mistake a delated appearance of
the placenta for a retention; thus, the mass may be detached and
lie loosely within the cavity of the uterus, or within the upper
part of the vagina, or partly within each, and not advancing any
further, may be erroneously considered a retention; whereas,

498

AMERICAN ECLECTIC OBSTETRICS.

some simple expedient, as firmly grasping the fundus uteri, blow-
ing in the hand or in a bottle, sneezing, coughing, bearing down, or
artificially producing retching, will at once liberate it. Ordinarily,
the last uterine pains which effect the delivery of the child, either
completely or partially detach the placenta, and the mass will
remain within the cavity of the organ until expelled by a
return of its contractions. When the detachment is partial, or
even when complete, dangerous hemorrhage may ensue, especially
when the uterus is in a state of inertia. If, however, no detach-
ment has taken place, and the placenta is entirely adherent to the
uterus, there will be no immediate danger from flooding.

The placenta may be retained without accompanying hemor-
rhage, and instances are recorded where it has remained within
the uterus for several days without causing any bad effects: cases
have likewise been met with where it never left the uterus, having
been, probably, absorbed by the uterine vessels. Several authors
have counseled us not to extract the placenta at all, unless hemor-
rhage be present, but leave it entirely to the natural powers; it
has, however, been found by experience that, more commonly, an
attention to this advice is fraught with danger to the female, who
becomes thereby exposed to hemorrhage, uterine inflammation, or
constitutional irritation from absorption of putrid animal matter,
as marked by vomiting, purging, and typhoid sjmiptoms. Severe
after-pains frequently accompany a retained placenta, but while
these exist, they are useful, being evidences of the contractions of
the uterus; still, the female often suffers unnecessarily from them,
by not having the after-birth expelled.

An accoucheur should never leave his patient with the placenta
undelivered, because she is not safe while it remains within the
uterine cavity; beside, any uncommon delay will give rise to men-
tal excitement and anxiety, from an apprehension on her part that
he is not thoroughly versed in his profession, or else that there is
some great danger present. Her friends will likewise be very apt
to increase her agitation and fears by whispered suggestions of
a similar character. And in case of a retention, he should remain
for an hour or two with her after the cake has been extracted, to
guard against subsequent hemorrhage.

In 259,250 cases, retention of the placenta occurred 293 times, or
about 1 in 661 J ; in 186 cases, 36 died, or about 1 in 5 ; the imme-
diate cause of the fatality being hemorrhage. — {Churchill.) Three
causes have been assigned for this difficulty: — 1, inertia of the

COMPLICATED LABOR — RETENTION OP THE PLACENTA, ETC. 499

uterus, or want of uterine contraction ; 2, spasmodic or irregular
contraction of the uterus; and 3, morbid adhesion of the placenta
to the uterus. These causes and their treatment will be considered
separately.

.1. RETENTION OF THE PLACENTA, FROM INERTIA
OF THE UTERUS, more frequently occurs after a difficult, pro-
tracted labor, though it may be due to a large pelvis, in which the
uterus is allowed to suddenly evacuate its contents — but, in the
latter instance, hemorrhage is apt to ensue, before the organ
can sufficiently recover, from its abrupt disgorgement, to contract.

Upon placing the hand on the abdomen, the uterus, instead of
being firm, hard, and well defined, indications of its normal con-
traction, will be found large, soft, and flabby, scarcely distinguish-
able, through the abdominal parietes, from the other viscera in the
hypogastrium ; there will be no pains, or, if they do occur, they
will be very feeble and indistinct.

TREATMENT. — Retention of the placenta, with accompanying
hemorrhage, has already been considered ; those cases will now
be referred to, in which flooding is absent.

The principal indication is, to adopt measures to induce uterine
contraction. For this purpose, frictions and firm pressure with
the palm of the hand over the fundus uteri, and at the same time
gentle tractions upon the umbilical cord in the direction of the
axis of the superior strait, should be made. In compressing the
uterine globe, in all cases where it is in a soft and flabby condition,
much care should be taken not to indent the organ, lest an inver-
sion of it be effected — for in a relaxed state, it will be an easy
matter for a careless or ignorant person to cause such a depression
by exerting an unnecessary amount of pressure. Again, in making
tractions upon the cord, too much force must be avoided, else it
may be torn from the placenta : or the placenta may be forced
from its uterine attachment, giving rise to profuse and dangerous
flooding; or the uterus may be either prolapsed or inverted.
Slight tractions upon the cord, to solicit or arouse the uterus to
action, are allowable ; but no attempts to draw out the placenta
by it should ever be made while the uterus is in a relaxed condition ;
any effort of this kind should only be attempted when the organ
is contracted, and then, the amount of force employed should be
moderate. Frequently, the sudden application to the abdomen of

500

AMERICAN ECLECTIC OBSTETRICS.

a napkin wet with cold water, or a sprinkling of cold water upon
the abdomen and thighs, will excite the uterus to action.

So also will coughing, blowing, sneezing, etc., or retching may
be produced by titillating the throat and fauces with a feather. If
these do not answer, Ergot may be administered; a drachm of the
coarsely powdered drug to be added to a teacupful of boiling water,
of which a tablespoonful should be given as a dose, repeating it
every ten or twenty minutes, until contractions are induced. Cimi-
cifuga, Caulophyllum, or their concentrated preparations, will fre-
quently prove more advantageous than the Ergot; the inner bark
of the Cotton root has been recommended, but I have never used
it in these cases. After a certain time, should the above means
prove unsuccessful, it will then become necessary to pass up the
hand and extract the placenta. The time necessary to elapse
before attempting this manual operation, is generally stated at an
hour, or an hour and a half ; yet, there can be no positive rule to
guide us ; for instance, when the labor has been very tedious and
severe, the uterus being sluggish and inactive, without hemorrhage,
the operation may be safely delayed for even a longer period ; and
in many instances of this kind, it will be found that the placenta
has been remaining nearly all the time in the upper part of the
vagina. It must be remembered, however, that the sooner after
delivery the more easily can the hand be introduced into the uter-
ine cavity, as the parts will be in a more relaxed condition ; and
the manipulation should never be delayed until the parts have so
far recovered their original firmness, as to render the entrance of
the hand painful and difficult. One hour and a half, under ordi-
nary circumstances, or three hours, in cases of extremely tedious
labor, may, perhaps, be considered the limits ; although I have, in
two instances, readily introduced the hand within the vaginal and
uterine cavities, and safely removed the placenta, seven hours after
the birth of the child ; in each case the labor having been very
protracted. The mode of removing the placenta has already been
described under the treatment of Hemorrhage during its retention.

Be extremely careful never to withdraw the hand from the
cavity of the uterus, holding the placenta, without first having
induced contractions of the organ; and should these not occur,
after the placenta has been detached, the hand must be kept in the
uterus, until they have been excited by some of the various
methods already recommended. And after the mass has been
abstracted, it should be carefully examined to ascertain that no

COMPLICATED LABOR — RETENTION OP THE PLACENTA, ETC. 501

portion of it has been left behind. The prudent introduction of
the hand into the womb for the abstraction of the placenta, is
always safer than the attempt by forcible traction upon the cord.
As soon as the placental mass has been delivered, do not fail to
secure the permanency of the uterine contractions, by the applica-
tion of the bandage, and if necessary, a compress.

Dr. Murphy, in his Lectures on Parturition, observes: "Reten-
tion of the placenta may arise from different causes. Sometimes
the sphincter of the vagina closes upon it, and the placenta is thus
retained until removed by the hand, or by firm pressure on the
fundus of the uterus. In other instances, the placenta remains in
the uterus after the delivery of the child, until it is expelled b}' its
subsequent contractions, rendered efficient by similar contractions
of the diaphragm and abdominal muscles. This additional aid is
required, inasmuch as the action of the uterus alone is not suffi-
cient for the purpose. Hence, when the abdominal muscles are
feeble, so that the uterus can derive no support from them, the
placenta is retained in this cavity. This cause of retention has been
generally mistaken for inertia of the uterus ; and, under this
impression, the placenta has been, very necessarily, withdrawn
from the uterine cavity. * * * When the child leaves the
uterus, a very powerful stimulus to its action is removed ; and this
stimulus the placenta is quite inadequate to supply. The uterus,
therefore, first ceases to act for a certain time, and when the action
is renewed, it is weak, and continues only for a short time. If the
uterus fails in discharging the placenta by a few of these efforts, it
becomes accustomed, as it were, to its presence, and it no longer
acts as a stimulus, but remains with the uterus imperfectly con-
tracted around it. A very efficient means of supplying this want
of irritation to the uterus, is the pressure of the abdominal viscera
which surround it. When the abdominal muscles are strong, they
contract upon the retiring uterus, compressing the intestines, and
consequently the uterus, on all sides. These weak pains, there-
fore, are greatly assisted and rendered effectual by the straining
efforts of the patient acting as a stimulus to the uterus from
without. But the abdominal muscles are not always strong; on
the contrary, in most instances, they are extremely weak, in con-
sequence of our civilized habits. They are too often reduced
almost to a state of atony from the constant pressure of the corset;
hence it follows that the uterus derives little or no support from
them, and the placenta is retained, not from any want of power

502

AMERICAN ECLECTIC OBSTETRICS.

in the uterus to expel it, but from a want of efficient stimulus to
cause the uterus to contract. There is no inertia of the uterus, but
only a suspension of its action. It is for this reason, and to
supply this deficiency, that the pressure of the hand on the fundus
of the uterus, during the expulsion of the child, is found so useful;
and, on the same principle, the application of a bandage round
the abdomen is always necessary, in order to give it proper
support."

2. IRREGULAR CONTRACTION OF THE UTERUS, termed
Hour-glass Contraction, sometimes accompanies retained placenta.
It may affect any part of the uterus, but is more commonly met
with at the os uteri. True hour-glass contraction is a strictured
condition of the central portion of the organ, dividing it into two
chambers, an upper one, which usually contains the placenta, and
a lower one; it is rarely met with in practice.

Sometimes the uterus contracts longitudinally upon the placenta,
having the shape of a cylinder or sugar-loaf; sometimes, there
will be a contraction of only one corner; at others it contracts
upon the placenta in a globular form ; again, the constriction at
the center, forming the true hour-glass contraction, may be met
with. The placenta may be completely inclosed above the
strictured part, or only partially, part of it being in the cavity
above the contracted portion of the uterus, and the remainder
passing through the narrowed section into the cavity below. The
placenta, in these cases, may be wholly or partially adherent, or it
may be detached. Prof. Meigs, believes the placenta to be always
adherent in hour-glass contraction; Dr. Douglass, of Dublin,
thinks it almost invariably occurs with morbid placental adhesion ;
so likewise does Dr. F. II. Ramsbotham, and in the cases which I
have met with, I have found placental adhesions to a greater or
less extent in each of them.

This irregular contraction of the uterus may exist in the longi-
tudinal fibers, or in the transverse, and more generally occurs after
a rapid delivery by violent and forcible pains. It may, however,
follow a protracted or preternatural labor, or a delivery of the
child effected by Ergot, and sometimes happens as the result of an
over-distended uterus. Not unfrequently an improper interference
with the cord, making traction in the wrong direction, and by
jerks, instead of a careful, continuous pull, will irritate the os uteri
and cause the womb to contract irregularly ; pressure and friction

COMPLICATED LABOR — HOUR-GLASS CONTRACTION.

503

immediately over the pubes instead of over the fundus uteri, has
also occasioned the difficulty.

Hemorrhage may, or may not be present ; and when it does
exist it is generally less profuse and alarming than when there is
a complete state of inertia, so that less haste will be required for the
extraction of the placenta ; this, however, will be found a more
difficult and dangerous operation, than in retained after-birth
without irregular or spasmodic contraction.

DIAGNOSIS. — Most instances of irregular uterine contraction
are impossible to detect by external examination. Generally, the
delivery of the child is followed by several severe and strong pains,
without any descent of the placenta, and which symptom, in con-
nection with a hard and enlarged condition of the uterus, when
felt through the abdominal parietes, and a full and turgid state of
the umbilical cord, may lead to a suspicion of the difficulty.

Should the uterus contract in the cylindrical form, it may be
detected through the abdomen, the fundus being felt at the epigas-
trium, and the body conveying to the fingers the sensation of a roll
or cylinder.

If it be a true hour-glass contraction, it may likewise be detected
by abdominal palpation. The uterus will be found to form two
tumors just above the pubis, the larger one of which contains the
placenta, while the smaller is joined to the other by a kind of neck,
which is the constricted central portion of the uterus.

But the more positive method of ascertaining the difficulty is by
an examination per vaginam. Passing the hand along the cord,
the cervix may be found hard and firmly contracted, resisting the
introduction of a finger, while the other hand placed upon the
abdomen, will find the uterine globe relaxed, or at all events, less
firmly condensed than the cervix. If the constriction is not at this
point, the hand must be carefully carried into the uterus, following
the cord, when it will, at some point, detect an aperture which
leads into the upper chamber, and, perhaps, a portion of the pla-
centa may be felt protruding through it. In this case, the lower
part of the uterus will be usually soft and flabby while the portion
above the stricture will be harder and firmer. The accoucheur
must not mistake this aperture for a rupture of the uterus ; for, it
must be borne in mind, that while the child escapes through a rup-
ture, the placenta seldom does.

TREATMENT. — This will depend somewhat upon the presence
or absence of hemorrhage. If it be present and profuse, the

504

AMERICAN ECLECTIC OBSTETRICS.

accoucheur will at once attempt the extraction of the placenta, in
the manner described hereafter : if it be not very profuse or alarm-
ing, he will proceed in his management more slowly and cautiously,
being governed, in this respect, by the effects of the loss of blood
upon the patient.

"Where hemorrhage does not exist, and the placenta does not
pass away, within the ordinary period, there is no necessity for
haste, unless, indeed, a true hour-glass contraction be ascertained,
when interference should be promptly attempted, there being, in
such case, but a small chance for the spontaneous expulsion of the
placenta.

In all other cases, where there are no additional circumstances
present requiring interference, attempts should not be made to
remove the placenta artificially, for at least an hour after birth of the
child. The treatment employed in the mean time, should be the same
as already recommended in retention from inertia, as constant pres-
sure over the fundus, slight but continued traction upon the cord
in the direction of the axis of the superior strait, etc., and which
will frequently subdue the spasmodic action, and effect a sudden
ejection of the placenta. An hour having passed without indica-
tions of an expulsion of the placenta, the manual operation will
have to be attempted. Introduce the hand into the vagina in the
usual way, and then into the uterus. If the constriction be at the
os cervix, gently and carefully introduce first one -finger and then
another, until, if necessary, the whole hand has entered ; but
frequently, the os may be dilated with two fingers, so that the
placenta may be seized and slowly worked out — and, sometimes,
this dilatation alone will remove the spasm and induce normal con-
tractions, followed by a delivery of the secundines.

If the contracted portion be higher up, the hand being guided
by the cord, will have to be passed upward until the constriction is
reached, and then, as before, first one finger, then another must be
introduced, gradually and steadily dilating the strictured part as
they enter, until the whole hand has been insinuated ; then, if the
placenta be adherent, it must be carefully and entirely detached, and
the hand and secundines suffered to pass out by the uterine con-
tractions only. If the mass be removed before the uterus acts,
hemorrhage may come on, hence it is important to induce the
action of the organ before withdrawing the hand.

The practitioner must not forget, while attempting the intro-
mission of the hand through the contracted aperture of the uterus,

COMPLICATED LABOR — HOUR-GLASS CONTRACTION.

505

to place his other hand upon the abdomen externally, and press
upon the fundus downward, in the direction of the operating hand.
If this be neglected, the womb may be so far elevated by the hand
within as to render it somewhat difficult, if not impossible, to enter
it. Sometimes the hand may be readily passed beyond the con-
tracted part; at others, time, perseverance, and gentleness, will be
required before the object can be accomplished.

Occasionally the contraction will be extraordinarily firm, and if
dilatation be effected, it will be followed by yet firmer contraction,
requiring so much force to enable the fingers or hand to enter, as
would be liable to cause laceration if the attempt be imprudently
persisted in. Such force must never be employed. If the placenta
can not be removed without violence, let it alone, and pursue the
course named under the treatment of Morbid Adhesion. In these
cases the uterus is usually in a very irritable condition.

Bleeding has been recommended in these instances, but it is a
very objectionable course, as it must not only unnecessarily debili-
tate the patient, but place her life in a very precarious situation,
should a profuse flooding from the uterus follow the relaxation
caused by it.

Chloroform has been exhibited in these instances, and I believe
with success, though I have had no occasion to employ it, having
always succeeded with the compound tincture of Lobelia and Cap-
sicum. Ergot has been advised, but, I think, upon unsafe grounds.

The compound tincture of Lobelia and Capsicum may be exhib-
ited either by mouth, or by injection into the rectum. I prefer the
latter mode, which is the one I have used the oftenest and with
decided success. The contents of the rectum having been first
removed by an enema, the above tincture, in the quantity of three
or four fluidrachms, may be at once injected. It usually acts with
promptness in overcoming the spasms, when the hand may be
introduced, if demanded. If, as may sometimes be required, it
becomes necessary to give this antispasmodic by mouth, one or
two fluidrachms may be taken for a dose. In cither case it must
not be diluted. It rarely produces a degree of relaxation sufficient
to give apprehensions of hemorrhage: generally, as soon as the
spasm has been overcome and the secundines removed, the uterus
contracts regularly and permanently. If much relaxation of the
system should follow its use, carbonate of Ammonia, Ether, or other
stimuli, will speedily effect a beneficial change.

In the exhibition of this tincture per rectum, it will sometimes
33

506

AMERICAN ECLECTIC OBSTETRICS.

be found, as I have experienced in my own practice, as well as
ascertained in that of others, that an introduction of the hand will
not be needed; for as the spasm is subdued, the uterus will act
normally, and the placenta will be expelled without any farther
assistance.

The tincture of Gelseminum has been advised, and I believe suc-
cessfully used, by some practitioners. I have had no opportunity
of testing its value in this difficulty, since its introduction into our
materia medica. That it will effect the desired relaxation, will
hardly be doubted by any one who has ever used it ; but whether
the persistency of its relaxing influence can be promptly obviated,
and a tendency to flooding thereby lessened or prevented, I am
not, from my own knowledge of its use in these cases, prepared to
say, although, in the absence of the compound tincture above
recommended, I think I should not hesitate to administer it, using
at the same time, however, a degree of watchfulness and prudence.
(Sec page 335.)

When the placenta is partly within the uterus and partly within
the vagina, the os uteri having contracted upon it, no attempts to
remove it by forcible pulling should be made, as this would be very
apt to tear it: the only method for its removal should be a gentle
dilatation of the os by means of the fingers.

When the placenta has been extracted, examine it carefully, as
has been heretofore recommended; and do not forget the necessity
for securing a regular, equal, and permanent uterine contractility.

For iregular pains, some practitioners exhibit a mixture of the
tinctures of Lobelia and Bloodroot, with a few drops of Lauda-
num. I have not employed it, but should consider it useful in
some cases.

3. PLACENTAL RETENTION from a MORBID ADHE-
SION to the UTERUS, is sometimes met with, and is of a more
critical nature than the previous varieties. It may exist in con-
junction with irregular contraction, or with inertia of the uterus,
which last renders it more formidable, from the dangerous hemor-
rhage apt to be present; frequently a few minutes decide the ques-
tion of life or death.

The adhesion may be complete, in which case there will be no
flooding until detachment ensues; or it may be partial, and com-
monly with hemorrhage. The copiousness of the discharge will

COMPLICATED LABOR — HOUR-GLASS CONTRACTION. 507

be in proportion to the extent of detached surface, and the num-
ber of vessels exposed.

The cohesive energy existing between the uterus and placenta in
these cases, varies considerably ; sometimes, the contractions of the
uterus are sufficient to detach and expel the mass ; at others, the
uterus may not be able to cause its separation, which, however, may
be readily effected by the hand; again, the cohesion may be so
great, as to resist any justifiable attempts to remove it with the
hand. And, instances have occurred where, after death, the sepa-
ration could not be accomplished by maceration, and also where it
was impossible to distinguish the line of demarcation between the
uterus and placenta when a longitudinal section of these organs had
been made.

The causes of morbid placental adhesion are not satisfactorily
known. By some authors the difficulty is attributed to a deposition
of calcareous or tuberculous matter, from the fact, that these have
been found in some portion of the placenta, usually on its maternal
surface. Again, it is believed by others, that whenever, from any
cause during gestation, an excitement or inflammation of the uterus
is produced, it may result in an eflusion of lymph, perhaps, forming
a new membrane, which more firmly consolidates the utero-placental
attachment. But, whatever, may be imagined on this point, it is
evident that morbid adhesion occurs altogether independent of the
character or management of labor, and is due entirely to abnormal
conditions, either of the placenta, or of the uterus, during preg-
nancy. %It is very apt to recur in the same woman, so that when
called to attend such cases (when known) the physician should be
more prompt in his movements than in ordinary instances.

DIAGNOSIS. — We can know nothing whatever of a morbid
adhesion, until the hand is introduced for the purpose of extraction.
It may be suspected, however, when several strong pains occur,
without any loosening of the placenta ; likewise, when the cord,
.being moderately drawn upon and then suddenly let loose, springs
upward with a jerk.

TREATMENT. — When hemorrhage is present, the case must be
managed as described under hemorrhage with retention of the
placenta. Hemorrhage requires the detachment and removal of the
placenta, or the patient will almost certainly die. If no hemor-
rhage exist, the adhesion, will be, probably, entire.

The early treatment of this difficulty, will be similar to that
advised in the preceding varieties — not knowing its true character.

508

AMERICAN ECLECTIC OBSTETRICS.

This failing, and an hour having elapsed, the hand must be intro-
duced, in the manner heretofore explained, to effect the detachment,
at which time the nature of the adhesion will be ascertained. The
placenta should be removed, if possible, even at the expense of con-
siderable trouble ; but sometimes, its detachment will be impossible.

In these latter cases, there is a diversity of opinion as to the
proper course to be pursued, many eminent accoucheurs advise us
to remove as much of the placenta as we can, even if it have to be
separated in pieces to accomplish this result ; while others, recom-
mend us to leave the mass in the uterus, until decomposition has
ensued, and then attempt its removal, or if this can not be done,
trust to the natural powers, aided by means to overcome the evil
results of putrefactive absorption.

"When the placenta can be removed without any great violence, it
should always be effected; but, if the reverse of this obtains, I think
I am warranted by my own experience, in connection with that of
many others, in recommending it to be left until decomposition
ensues, when a safer opportunity for its extraction may be offered.
The tendency to hemorrhage will be less when the whole mass is
thus left behind, thah when a portion of it has been torn off' and
removed, the rest remaining adherent. These entire and extremely
tenacious adhesions are fortunately quite rare.

In these several instances of retained placenta, no attempts should
ever be made to remove it by forcibly pulling upon the cord ; neither
should the placenta itself, provided a part of it can be seized, be
drawn upon, until it has been satisfactorily ascertained that it is per-
fectly loose, and that no portion of it is retained in a firmly con-
tracted os uteri. Otherwise, an inversion of the uterus may be
produced, or, the placenta may be torn, and the remaining adherent
portion of it within the uterus, occasion a subsequent hemorrhage.

Should the UMBILICAL CORD BE RUPTURED, then, after
a failure of the means heretofore recommended for procuring uterine
contractions, the hand must be very carefully and gently introduced,
within the uterus, the placenta sought for, detached, and removed
in the usual manner, being particular to remove it entire, in order
to avoid an attack of flooding.

When the placenta is so FIRMLY RETAINED by THE IRREG-
ULAR CONTRACTION" OF THE UTERUS, or by MORBID
ADHESION, as to resist all legitimate endeavors to remove it, or
when portions of it have been permitted to remain in the uterine

COMPLICATED LABOR — RETENTION OF THE PLACENTA, ETC. 509

cavity, the mode of treatment will depend somewhat upon the symp-
toms which follow.

Generally, severe after-pains are experienced, which interfering
with the patient's sleep and quiet, render her very irritable — and
these pains are augmented on pressure over the uterine tumour, or
when the child is applied to the breast. The discharge from the
uterus is at first of a normal amount, and clots are occasionally
passed off with it ; but in two or three days, its character changes,
becoming of a dark brownish color, excessively fetid, and accom-
panied with pieces of the decomposed placenta. This happens,
more especially, when only a portion of the mass is left behind.

Soon after putrescency has commenced, from an absorption of
the putrid animal matter, a severe irritative fever attacks the
patient, manifesting itself at first by rigors. The pulse becomes
small and rapid, the skin, and especially that on the abdomen,
becomes hot and dry, pain in the head, of a diversified character
comes on — it may be continuous, and accompanied with beating
or throbbing, or, it may be intermittent, sharp, and darting. The
tongue is at first white, and slimy, or red, shining, and dry ; the
thirst is inordinate ; vomiting is frequently present, or a choking
sensation, particularly when the patient endeavors to drink; there
is constant restlessness and wakefulness, with mental anxiety,
which is plainly depicted upon the countenance. The secretion of
milk diminishes; the bowels, at first very torpid, become so exces-
sively loose as to resist the attempts made to check their action.
Most usually, erratic pains, of greater or less severity, are present,
shooting from one hip to the other, perhaps locating in the neigh-
borhood of the diaphragm and interfering with respiration, or,
shifting from one part of the body to another. These symptoms
continue to increase, the tongue becomes coated brown or black,
the abdomen becomes tumid and tense, the strength rapidly fails,
the extremities become cold, vomiting of a dark-brownish granu-
lar-like substance occurs, with low delirium, involuntary evacua-
tions of the feces and urine, subsultus tendinum, and in ten or
twelve days following delivery, the case terminates fatally.

Ramsbotham states, that "upon dissection, the veins of the
uterus are generally found inflamed, and containing pus ; the
uterus itself, to a greater or less extent, partakes in the inflamma-
tory disposition, and is perhaps gangrenous; or purulent deposits
are observed in its substance ; and perhaps also in or around some

510 AMERICAN ECLECTIC OBSTETRICS.

of the larger joints, or among the tendons, or within the fleshy
muscles of the limbs."

Sometimes, the placenta is expelled in twelve or twenty-four
hours without putrefaction, or any unpleasant consequences ; at
others, it has been expelled in a putrescent condition, but without
causing any irritative fever ; and again, in some rare cases, it has
never been discharged nor produced any injury to the general
health, but has, as supposed by some writers, either been absorbed,
or continuing adherent, become organized.

A very favorable indication when putrid absorption takes place,
is, to observe that the symptoms are less violent, and the discharge
of a puriform character, containing portions of the placenta, having
but little or no fetor, and accompanied by no great amount of pros-
tration of the vital powers.

TREATMENT.— When it is ascertained that the placenta can
not be removed, a bandage should be applied around the body, in
the manner heretofore indicated, with a compress over the fundus,
and in two or three days, the attempts to abstract the mass should
be cautiously and gently renewed. However, should the pains at
any time become very severe and continuous, or the presence of
the bandage appear to increase them, it must be removed.

When the placental mass can not be artificially abstracted, or
when portions of it have been left adhering to the inner uterine
wall, and, in either case, putrescency occurs, the indications of
treatment will be, to subdue inflammation, correct the fetor of the
discharge, and support the vital powers : and for the fulfillment of
these, various remedies may be used.

When there is hemorrhage, it must be combated by the means
already indicated. When the fever is very high, with great irri-
tability of the system, to subdue it, and neutralize to a greater or
less extent the influence of the absorbed matter, a mixture of five
grains of the compound powder of Ipecacuanha and Opium, with
one grain, each, of Sulphate of Quinia, and Baptisin, may be
administered for a dose, and repeated every two or three hours.
Or, two parts of the compound tincture of Virginia Snakeroot,
may be combined with one part, each, of tincture of Gelseminum,
and tincture of Wild Indigo, which may be exhibited every few
hours in teaspoonful doses. When the influence of these agents is
once obtained, by continuing it, together with the other means to
combat putrescency, the tendency to vomiting will be considerably
lessened. Should there be a great amount of pain, tincture of

COMPLICATED LABOR — RETENTION OF THE PLACENTA, ETC. 511

Aconite root may be used in conjunction with either of the above
preparations. The bowels should be kept free by Seidlitz Powders
and mucilaginous, laxative injections; and when they become
immoderately loose, the tincture of Chloride of Iron may be given
in doses often or twenty drops in sufficient water, and repeated
according to the urgency of the case ; at the same time the follow-
ing injection should be used very frequently, viz. : Take of com-
pound tincture of Virginia Snakeroot one fluidrachm, Tannic acid
ten or twenty grains, Water half a fluiclounce — mix. I have found
this course more effectual in restraining the discharges, than any
other with which I am acquainted. (See Putrefactive Absorption,
page 190.)

For a constant drink, during the irritative stage, an infusiou of
Marsh-mallow root, or of Elm bark, or either of these with the
addition of Peach leaves, or Wild Cherry bark, may be taken freely;
lemonade may also be allowed, or tamarind water, prune water,
etc., if craved by the patient.

The surface should be frequently bathed with warm water, or an
acidulous solution. In. some instances a warm saline solution will
be found more efficacious.

To overcome the fetor, and aid in removing the loosened putrid
portions, a tepid solution of Chloride of Lime, or Chloride of Soda,
diluted Pyroligneous Acid, or infusions of Wild Indigo leaf, or
bark of the root, or of the White Oak bark, or even of brewer's yeast,
may be injected into the uterus and vagina several times a day.
Too much force must not be applied in introducing the fluids into
the uterus, lest they be passed into the canal of the Fallopian tubes.
A solution of Borax injected into the uterus has been suggested,
but I should hesitate about employing it in this manner. I
prefer the diluted Pyroligneous Acid.

As soon as symptoms of prostration manifest themselves, the
above internal treatment must be changed. To overcome the
depressing influences of the absorbed putrescency, brewer's yeast
may be given internally, ale or porter may also be allowed, and
good cider will be found a most salutary and refreshing draught;
it may be exhibited frequently. And in the absence of these, an
endeavor should be made to sustain the system by wine, ether,
ammonia, aromatics, etc.

In conjunction with these, some preparation of Peruvian bark
or Quinia must be given. A very excellent mixture is composed
of Sulphate of Quinia, three grains, Baptisin, half a grain, Leptan-

512

AMERICAN ECLECTIC OBSTETRICS.

drin, one or two grains ; mix for a dose, and repeat as required.
It may be given in some Quince or Blackberry syrup or jelly.
Various other agents may also be used, combined to suit the indi-
cations, as well as views, of the practitioner, as, Xanthoxylin,
Hydrastin, Ptelein, etc. The female should be kept cleanly, and
the apartment which she occupies be well ventilated, and main-
tained at a moderate temperature.

CHAPTER XXXIX.

COMPLICATED LABOR INVERSION OF THE UTERUS RUPTURE OF THE UTERUS RUPTURE

OF THE VAGINA RUPTURE OF THE BLADDER SYNCOPE THROMBUS.

When attempts are made to abstract the placenta by forcibly
pulling upon the cord, and especially if these be made when the
uterus is in a flaccid condition, the cord may be broken, or the
uterus may be inverted. INVERSION OF THE UTERUS may
likewise be occasioned by a rude attempt to effect a removal by
pulling upon the placenta itself. It may also be owing to a rapid
delivery in a large pelvis; to a short umbilical cord; to delivery
taking place when the female is in the erect posture ; to violent
straining during the last pains of the second stage ; and it is stated
to have occurred spontaneously, or without any satisfactory causes;
but, by far the majority of inverted uteri are caused by improper
management of the accoucheur.

This accident may occur immediately after delivery, when it is
termed acute or reducible inversion ; it may not take place for a few
days after, in which cases, however, it is stated that a depression
of the fundus existed from the first ; or, it may happen gradually,
in which case, as well as when the acute form has not been removed
it is called chronic or irreducible inversion. Sometimes it takes place
in the unimpregnated uterus, being occasioned by the presence of
a tumor, the growth of which enlarges the organ, until its weight
carries it through the os with the fundus attached to it.

An inversion of the uterus is one of the most serious accidents
that can befall the parturient female. About one-third of the cases
prove fatal, either in a very short time, or within a month after its
occurrence. Of one hundred and nine fatal cases recorded, seventy-

COMPLICATED LABOR — INVERSION OF THE UTERUS.

513

two died in a few hours; eight in from one to seven days; six in
from one to four weeks : or eighty-six in one month.

SYM PTOMS.— The inversion may be partial or complete. When
it is partial, a portion of the uterine wall, but more commonly the
fundus, is depressed within the uterine cavity, presenting, internally,
a convex surface. This form may prove fatal. It can be detected
only by introducing one or more fingers within the uterus, which
will discover the convexity of the depressed part, and by external
palpation, which will, if the depressed portion be situated anteriorly,
discover the concavity formed by it, instead of the usual globular
form of the womb. It is apt to induce violent straining and bear-
ing down efforts, which may eventually occasion a complete inver-
sion ; and which efforts, to any great extent, should always be pro-
hibited, after the birth of the child, especially when the uterus is
in a non-contracted condition. There maybe no pains with it, but
a sensation of sinking. Hemorrhage usually accompanies it, and
in cases where this is obstinate and long-continued, it may be
owing to a depression of the above character, which should be
ascertained by passing one or two fingers within the uterine cavity.

Again, in a partial inversion, the advance or depression of the
fundus may be so extensive as to be grasped by the inferior part of
the uterus, or even pass through the os uteri, but without chang-
ing the situation of the cervix. In this case the palpation will
discover a greater amount of concavity, or perhaps a vacuity above
the pubes, and the finger will detect the fundus filling the lower
part of the uterus, feeling like an elastic tumor, more or less pain-
ful, or it may be felt protruding through the os into the vagina,
being soft and convex, and the hand, by being passed up, can
recognize the encircling cervix. The pulse will become small,
rapid, and fluttering, with sudden prostration or sinking of the
vital energies, which happens independent of any hemorrhage;
also paleness of the countenance, nausea, vomiting, and violent
bearing-down efforts. The presence of flooding increases the
danger.

In complete inversion, the cervix, as well as the whole body, is
inverted; the uterus is completely turned inside out; it maybe
retained within the labia, but more generally a greater or less pro-
portion of it will be found externally, from an accompanying pro-
lapse and inversion of the vagina. Sudden hemorrhage and
sinking occurs, with a sensation of fullness in the vagina, and
frequently death supervenes before the practitioner is aware of the

514

AMERICAN ECLECTIC OBSTETRICS.

accident. If this does not take place immediately, all the symp-
toms above enumerated exist in a greater degree. Should the
uterus contract, hemorrhage will, probably, be absent.

"It will sometimes happen that, for hours after the accident, not
a single pressing symptom shall occur. In general, however,
when a womb is left in the inverted position, the patient is still
liable for hours, and days afterward, to large and even fatal erup-
tions of blood, of which I have myself been a witness ; add to
which, that independently of the flooding, mere displacement of
the parts may, perhaps, give rise to more or less collapse ; obstruc-
tion of the bladder, too, is not unfrequent, and the introduction of
the catheter may become necessary." — (Blundell.)

DIAGNOSIS. — Great care must be taken not to confound an
inverted uterus with some other difficulty. It has been mistaken
for a head, or a breech presentation of another child, for a pla-
centa, a polypus, a mole, a clot, an excrescence, etc.; and instances
are not wanting, where the uterus, mistaken for something else,
has been torn from the female by an ignorant practitioner, occa-
sioning the most agonizing torture, followed by a rapidly fatal ter-
mination.

In connection with the symptoms and examinations named
above, the uterus will be recognized, when its inversion is com-
plete, by its rough, flocculent, and bleeding surface, and by its size
and shape. If it can be inspected visually, the fibrous tumor will
be of a red color, but which gradually changes to a dull brown
when the difficulty becomes permanent.

PROGNOSIS. — Those cases which occur spontaneously are said
to be more hazardous than those occasioned by traction of the
cord; and the rapid attack of the inversion, accompanied with
uterine inertia, greatly augments the danger. The more incom-
plete the extent of the inversion, and the more slowly it occurs,
the more favorable will it be for the patient.

Usually, the hemorrhage, or the severe shock upon the nervous
system occasions the death of the patient. Sometimes the inverted
organ becomes inflamed, and, being strangulated by the contraction
of the cervix, gangrene and sloughing ensue, followed by death;
cases, however, have been recorded where such a condition has termi-
nated favorably. Again, when patients have passed safely through
the early period of inversion, they have been known to live for
many years, without its occasioning them much annoyance; of
course, in these instances, the organ very much diminishes in size.

COMPLICATED LABOR — INVERSION OF THE UTERUS. 515

Occasionally, the tumor becomes attacked by some malignant form
of disease.

. Spontaneous reduction of partial inversions, as well as of chronic
inversions, are recorded to have been met with. A ready reduc-
tion of acute cases is not always successful, as the patient may
have been too much exhausted before it was accomplished; or, it
may be followed after a few days, or even months, by death, the
consequence of the violence which the uterus has suffered. Gen-
erally, in these latter instances, the danger returns with the cata-
menia.

TREATMENT. — In partial or incomplete inversion, two or
three fingers, or the whole hand, if necessary, may be introduced
within the uterine cavity, and the depressed portion be gradually,
but continuously pushed upward. When the reduction is finished,
provided the whole hand has been introduced, it should not be
removed until contractions have taken place, or else, the inversion
may be renewed, or, hemorrhage ensue.

"When the inversion is ^complete, its reduction should be at-
tempted without delay, because, the longer it remains without
re-position, the more difficult will be the operation. A delay of
an hour or two may render any successful endeavors impossible;
and its continuance for one or two days, generally renders it irre-
ducible. However, a few rare cases are recorded in which re-pos-
ition was effected after eleven weeks had transpired, and one of
sixty-six weeks ; but such cases are exceptions, and should never
be anticipated. Spontaneous reduction of chronic inversion has
been noticed by several writers.

In effecting the reduction, it will be found that it can be accom-
plished with greater facility, the sooner it is undertaken after the
occurrence of the accident. There are several modes advised for
the operation. One is to grasp the uterus with both hands, lessen-
ing its bulk, and steadily pressing upward, so that the mouth, then
the cervix, the body, and the fundus, successively pass into their
natural positions ; this, however, is rather a difficult method, as
the pressure exerted upon the organ by the hands, will be very
apt to occasion contractions, during which all attempts will be
futile.

Another method is, to firmly press the back of the fingers
against the fundus, the hand being held in a half-closed condition,
and effect the replacement in this manner, which usually takes
place with a jerk.

516

AMERICAN ECLECTIC OBSTETRICS.

But, probably, the best mode is, to place the fingers in a conical
form, press them, thus closed, upon the fundus, indent it, and
carry it upward through the os uteri, the body and neck necessa-
rily following.

Several points, however, are necessary to be attended to. The
female, if not too much exhausted, must be placed on her back,
with the hips considerably elevated above the chest (though when
the reduction is attempted immediately after the inversion, this is
not so essential), and the legs and thighs flexed and separated.
The hand to be employed should be well oiled, and the operation
should not be undertaken, nor persisted in, while the organ con-
tracts, but only during its state of softness and relaxation. Before
attempting the indentation of the fundus, the inverted organ must
first, if possible, be pushed up beyond the vaginal orifice, and no
effect will be produced until the upward pressure shall have caused
some extension of the vagina. The pressure should not be made
against the pubic arch, but in the direction of the axis of the pelvic
cavity, and to correspond as nearly as possible with its center; the
practitioner must not forget the direction of the axes of the straits
and pelvis during the operation, as this will only be successful by
carrying the fundus upward in their line. Should the perineum
interfere with the operation, press it backward while passing the
organ by it. The pressure should be firm and continuous, making
no effort when the uterus contracts, except that of securing what
has been gained, by resisting any tendency toward a return to its
first misplaced condition. Most commonly the fundus returns to
its normal situation, by a sudden jerk, or start, somewhat like
a gum-elastic bottle when turned inside out. Too much force
should never be employed in the operation, lest the uterus or
vagina be lacerated ; a moderate force, steadily persisted in, will
prove the safest and most successful. Whatever may be the
extent of the inversion, after its reduction, the hand being within
the uterine cavity, should be retained there until the contractions
of the organ expel it, using means to forward these if required;
and be certain that the restoration is complete before allowing the
hand to be expelled. A depression of the fundus remaining, may
occasion violent bearing-down efforts, followed by a return, and
perhaps an irreducible state, of the inversion.

The inversion may happen with complete detachment of the
placenta, or it may be more or less adherent. When adherent,
there is a diversity of opinion as to the management, some recom-

COMPLICATED LABOR — INVERSION OF THE UTERUS.

517

mending it to be removed, before proceeding with the re-position,
and others advising us not to remove it, until the restoration has
been completely established.

When the uterus is in a relaxed state, arid the placenta is com-
pletely adherent, or nearly so, to remove it would be very apt to
cause a hemorrhage which might prove suddenly fatal ; or uterine
contractions might follow the detachment, rendering a reduction
of the inversion very difficult, or altogether impossible; hence, in
such cases, it were better to return the placenta with the uterus,
before detaching it.

When the placenta is detached to a considerable extent, and the
remaining adhesions can be readily separated, it may be proper to
attempt this previous to the reduction ; unless the hemorrhage
from the vessels already exposed be very profuse, when the safest
course would be to abstract the cake only after the replacement of
the uterus. A slight and easily-separated adhesion, can not seri-
ously augment the flooding, hence, its removal should be accom-
plished before the operation.

There may be cases in which it will be impossible to return the
uterus while the placenta adheres, and here the difficulty will be
very great ; a detachment of it may be followed by dangerous
hemorrhage, or by contractions which will interfere with the suc-
cess of the operation. The case is necessarily one of danger, shall
we increase the risks by removing the placenta? Perhaps it may
be a better course than to run the chances of a chronic inversion.
I can not speak from experience ; but whichever course is adopted,
be certain that the reduction is impossible, by a persevering effort,
and that the obstacle is the presence of the placenta, and not
improper or badly-directed efforts. Several writers state, that in
such cases, they have detached the placenta without any subse-
quent bad results.

Exhaustion and depression of the vital energies must be com-
bated by stimuli and appropriate treatment, similar to that laid
down when speaking of hemorrhage. The female should not be
allowed to get up too soon after the reduction, keeping her in a
horizontal position, with the head depressed and the hips consid-
erably elevated, the knees and thighs being bent, and all strainings
at stool should be forbidden, keeping the bowels free by mild laxa-
tives or injections.

When the uterus has once been inverted during a labor, it has a
strong disposition to renewal of the difficulty in consecutive ones;

518

AMERICAN ECLECTIC OBSTETRICS.

therefore, with such patients it will be improper to make any trac-
tions upon the cord to abstract the placenta; if pressure upon the
fundus with frictions will not expel it, the best course will be to
introduce the hand within the cavity of the uterus, and remove
the mass in the manner heretofore explained.

If the inversion has been of several days' standing, it has been*
advised not to omit attempts at the reduction, from the fact that it
has been reduced, in many instances, after a lapse of weeks and
even months. Probably, the Compound tincture of Lobelia and
Capsicum might aid in causing sufficient relaxation to permit its
reduction; but from the nausea and vomiting which this might,
probably, produce, I would prefer the following plan : Having
emptied the bladder and rectum, place the patient under the relax-
ing influence of the tincture of Gelseminum; at the same time,
Bhould the uterus be external to the vulva, envelop it in cloths wet
with warm water, without permitting any evaporation to take
place, changing them from time to time, if necessary. Relaxation
of the muscular fibers of the organ having followed this course,
then attempt the reduction. I have never had an opportunity of
trying this method, but merely suggest it to the profession; from
a knowledge of the influence of the agents named, upon the sys-
tem, I believe it will be found successful in very many instances
of chronic inversion. At all events I should try it, before under-
taking any of the severe and painful methods recommended for
removing the uterus.

After the replacement of a chronic inversion, the female should
be treated the same as advised under the acute form; and, in either
form, it may be beneficial to protect the uterus, for a number of
Weeks or months, from the superincumbent weight of the intes-
tines, by the application of an abdominal supporter immediately
below the umbilicus, whose force shall be directed inward and
upward.

"When the inversion can not be overcome, palliative measures
are all that can be recommended, and if the uterus falls out of the
vulva, it should be placed beyond external danger, by returning it
within the vagina, and retaining it there by a bandage and com-
press; at the same time using the abdominal supporter above
referred to.

It has been advised by several eminent writers to remove the
uterus, in irreducible cases, by the ligature, or the knife; and
instances are not wanting where its extirpation by these means, or

COMPLICATED LABOR — RUPTURE OF THE UTERUS.

519

by gangrene and sloughing, the result of its strangulation by the
os uteri, has resulted favorably. Still, as long as the female expe-
riences no great amount of discomfort, or any alarming symptoms,
I can see no necessity for the operation — it appears to me cruel and
uncalled for, especially when we bear in mind, that females have
labored under this accident for many years without any very
unpleasant or exhausting symptoms. Beside which, cases of spon-
taneous reduction have been recorded, in which pregnancy subse-
4» quently occurred.

However, should the uterus be attacked by some malignant dis-
ease, while in this displaced condition, its extirpation may be fol-
lowed by favorable results. The ligature employed is usually
either silk, silver- wire, or whip-cord; it may be applied around
the uterus at its highest part, and gradually tightened as the patient
can bear it, until the separation has taken place. Should it cause
any violent symptoms, it must be loosened for a time, until these
have been subdued. The strength of the patient must be kept up
by a non-stimulating, nutritious diet.

"When the knife is employed, a ligature should be first applied
as above, for the purpose of preventing hemorrhage, and the ex-
cision be made immediately below the ligature. In a case where
extirpation of the inverted uterus would be desirable, instead of
the preceding operations, I would first endeavor to remove it by
means of Galvanic Heat, which I believe would effect it without
the loss of much blood, or any subsequent dangerous inflammation.
This heat may be applied, by attaching a platina point to the end
of a copper or iron wire, then, by bringing the two poles of a gal-
vanic battery to act upon this point, a heat will be obtained of
sufficient intensity to destroy all animal tissues to which it may be
applied, without any great degree of suffering. I have used this
successfully in fistula in ano, and urethral stricture.

Occasionally, instances of a RUPTURE OF THE UTERUS are
met with, which generally prove fatal. This accident may occur
during pregnancy, or at an advanced period of life, but it is only of
its existence during parturition that I shall treat.

Rupture of the uterus occurs more frequently among multipara?,
and especially, it is stated, with male fetuses, who are usually larger
than females ; it may be owing to several causes, as, a debility or
disorganization of the uterine tissue, effected by inflammation
during pregnancy ; cases of thinning, softening, scirrhus, and gan-

520

AMERICAN ECLECTIC OBSTETRICS.

grene of the uterine walls, have been recorded. An abnormal size
of the fetal head, may be a cause ; as well as obliquity, or retrover-
sion of the uterus — transverse presentation of the body, or the head
presenting obliquely at the superior strait ; the presence of a
polypus; an excess of liquor amnii; and plurality of children, have
all been named as causes. It may occur from violence, as falls,
blows, forcible attempts at delivery by turning or otherwise, and has
been known to follow a fit of anger. A rigid os uteri may occasion
it, and instances have been observed where the os has been entirely
torn off; females who have deformed pelves, or those on whom the
Cesarean operation has been performed at a previous labor, are very
liable to it. Violent efforts of the uterus itself, and especially when
induced by the exhibition of ergot, or stimulants, will tend to
lacerate the organ.

Among these enumerated causes, probably, those which more
frequently give rise to the accident, are morbid alterations in the
uterine tissue ; violent contractions of the uterus ; a forcible entrance
through the undilated os ; and undue violence in turning, or other-
wise assisting the delivery ; though, it may occur during the opera-
tion of turning, from some diseased state of the cervix, the operator
being blameless. The rupture may happen at any part of the
uterus, though it is most frequently met with at the cervix, either
anteriorly, opposite the pubes, or posteriorly, opposite the sacral
promontory, and generally at the point complained of by the
patient as being excessively painful. Its direction is not constant —
with some it may be longitudinal, and with others oblique or trans-
verse ; and it may be accompanied with a laceration of the vagina.

Its occurrence may be sudden, or it may take place gradually ;
and the laceration may be complete, extending through the uterine
texture and its peritoneal covering ; or, partial, being confined only
to the peritoneum, or to the muscular texture.

SYMPTOMS. — Rupture of the uterus most frequently follows a
powerful effort of contraction, during which the female suddenly
screams that something has ruptured within her. The pain accom-
panying this sensation is very acute and agonizing, and is frequently
expressed as " a crampy pain ;" and it is the intensity of this which
causes the shrieks of the patient. Frequently the rupture is mani-
fested to the bystanders by a tearing or cracking noise.

The pains soon become feeble, or cease immediately, according to
the complete or incomplete nature of the rent, and a violent, con-
stant, excruciating pain, entirely different from that caused by

COMPLICATED LABOR — RUPTURE OF THE UTERUS.

521

uterine contraction, is most generally complained of, as being con-
fined to one spot.

The pulse soon becomes rapid, small, feeble, and fluttering ; the
countenance quickly assumes a pallid, anxious, and alarmed appear-
ance; the respiration becomes hurried and difficult; the surface is
cold and clammy ; violent retching ensues, with vomiting of mucus,
a greenish matter, or a dark-colored substance resembling coffee-
grounds ; there is faintness, with an inability to lie, requiring the
female to be raised in the bed ; external or internal hemorrhage may
occur, but the flooding is frequently absent, there being but a slight
discharge of blood ; and sometimes convulsions happen.

Should the peritoneal coat only be rent, the labor may go on, and
the child be delivered ; and, occasionally, the last pains which
expel the child, may at the same time effect a complete rupture of
the uterus.

DIAGNOSIS. — In connection with the symptoms above named,
an examination, externally, will discover the uterus contracted in
one or the other iliac region, and the child may be plainly detected,
through the abdominal parietes, when the rupture is complete. An
examination per vaginam will ascertain that the presenting part has
receded so as barely to be felt by the finger, unless it be impacted,
or, it may have passed entirely out of reach, the child having
escaped into the cavity of the abdomen. The death of the fetus
generally happens immediately, so that if the [fetal pulsations can
be heard, it if considered indicative of no rupture. A partial rent is
of more difficult diagnosis ; we must be guided by the pain, and
the collapsed condition of the patient.

PROGNOSIS. — The prognosis is always serious, as very few ever
recover from the accident. The shock may destroy the patient
immediately or in a few hours after the rupture; if the collapse does
not prove fatal, she may die subsequently of peritonitis, or, second-
ary affections may finally destroy her, as lumbar abscess, sub-peri-
toneal abscess, etc. Even slight lacerations of the os uteri have
proved fatal. If the peritoneal coat be not ruptured, there will be
danger of peritonitis. Metritis will be apt to follow a laceration of
the muscular tissue.

Although the fatality attending this casualty is very great, still,
cases are recorded in which recovery has followed, and even where
children have been given birth to, subsequently; so that in no case
is the practitioner to abandon it as irrecoverable — his duty is to use
every effort to save his patient.
34

522

AMERICAN ECLECTIC OBSTETRICS.

TREATMENT. — In a labor where, from the violence of the
pains, or the presence of a fixed, crampy pain, or other well-
founded reason, rupture of the uterus is apprehended, the delivery
should, if possible, be hastened — but not by Ergot, or stimulants.
It would also be advisable to moderate the pains by the agents
heretofore named, as tinctures of Gelseminum, Aconite root, etc.
The forceps should be employed when safe and practicable; but if
the child be dead, and any resistance be offered to its advance by
the forceps, the perforator should be used. Counsel should always
be sent for.

If the rupture has occurred, the only chance for the patient is
in immediate delivery. If the head be within reach, the child may
be cautiously extracted with the forceps; or, if this can not be
effected, then Ahe perforator must be used, taking especial care^
with either instrument, not to push up the head, lest it slip
through the rent into the abdominal cavity. This may be avoided
by an attendant making pressure over the fundus, and the opera-
tor causing the perforation to be gently made in a direction, as
much as possible, toward the sacrum. Should the presentation be
of the shoulder, or the face, or the nates, bring down the feet, and
thereby hasten the expulsion, as well as prevent the child from
passing into the abdominal cavity. The child being delivered,
follow the cord, and carefully remove the placenta.

If the child has passed into the ventral cavity, the hand and arm
should at once be oiled and insinuated steadily alor% the vagina,
into the uterus, and through the rent into the cavity of the abdo-
men; the feet of the child should then be seized and brought
down, extracting it through the ruptured opening into the uterus
and delivering by the natural passages. This accomplished, rein-
troduce the hand, if necessary, to remove the placenta. But in
either case, be especially careful not to abstract any portion of the
intestines along with the child, or placenta; and if any part of
them has entered the fissure, remove them, that they may not be
strangulated by the subsequent contraction of the uterus. Make
no attempts, however, toward their proper replacement; when
remaining within the abdomen any interference to adjust them is
improper.

But the os uteri may not be dilated, or not sufficiently so for the
introduction of the hand, or, after the child has escaped through
the rent, the uterus may contract — in either case — rendering
delivery by the natural passages impossible; what must be done?

COMPLICATED LABOR — RUPTURE OF THE UTERUS.

523

It is advised by eminent authority, that if the female has not
suffered much from the shock, and other circumstances are favor-
able, to explain to her the nature of the accident, and with her
consent, perform the Cesarean section, and remove the child and
placenta through the abdominal parietes. If, however, she be
rapidly sinking, or half an hour has elapsed, and the fetus is dead
leave the case to nature. The practitioner will however be guided
by circumstances, everything will depend upon his judgment
aided by that of his counsel, and no safe means must be left
unemployed which may tend to preserve both mother and child.

While the patient is in a collapsed condition, various agents may
be given to arouse the vital energy, and prevent it from becoming
too far depressed. Stimulants, as Wine, Camphor, Ether, Ammo-
nia, etc., should be given, being careful not to carry their use so
far as to increase the danger by aggravating the reaction; also
apply stimulants externally.

After the delivery, Opium, Morphia, compound powder of
Ipecacuanha and Opium, Hyoscyamus, or other anodyne may be
given. The subsequent inflammation must be met by tincture of
Aconite root, tincture of Gelseminum, or, compound tincture of
Virginia Snakejoot, etc., which should be exhibited freely so as to
effect a speedy influence upon the system. Poultices or fomenta-
tions of Hops and Stramonium leaves, over the abdomen, with the
internal use of mucilaginous diuretics, will also be found of much
benefit.

The VAGINA MAY BE LACERATED, in connection with
the uterus, or independent of it ; it is more unfrequent than uterine
rupture. The symptoms resemble those of rupture of the uterus,
and are nearly as dangerous. If the laceration be trifling, it is
better to leave the case to nature, watching it carefully, however
and bestowing some care to the support of the perineum, as the
head passes over it. If there be danger of an extension of the
laceration, hasten the delivery, by forceps if possible. The after-
treatment will be similar to that in the preceding accident.

RUPTURE OF THE BLADDER, is a more fatal occurrence
than that of the uterus, it is extremely rare, and may arise from
neglect or inattention of the practitioner, or the improper use of
instruments. Its symptoms are somewhat similar to those of rup-
ture of the uterus, as a violent and severe pain in the region of

524

AMERICAN ECLECTIC OBSTETRICS.

the bladder; a scream from the patient; a sensation of something
having given way internally ; rapid depression of the vital powers;
tumefaction and tenderness of the abdomen ; but no recession of
the presenting part, or distinguishing the child in the abdomen.
The contractions of the womb continue, but grow weaker as the
system sinks.

This accident may be prevented by proper care on the part of
the practitioner, who will ascertain that the organ is emptied dur-
ing labor, or if it be full, and the patient can not void the urine,
he must introduce a flexible catheter and thus effect the evacua-
tion. When the rupture occurs, the child should be saved, if pos-
sible, there being but little hope for the mother. The delivery
should be hastened by turning, or the forceps, if the child be alive;
and if this can not be effected, the Cesarean operation has been
advised. The death of the child usually ensues in consequence of
the prostration of the mother.

SYNCOPE, occasionally attacks females either during labor, or
subsequently thereto, and may occur independently of hemorrhage,
or rupture of the uterus, vagina, or bladder.

Those of a nervous, hysterical, delicate habit, are more liable to
it, though it is also met with among those who have prostrated
the energies of the system by intemperance, or unhealthy diet with
impure air. It may also be occasioned by some organic disease, as
of the heart and lungs, or from the rupture of an aneurism, or
abscess, in which instances it may prove fatal. It also undoubtedly
occurs from the sudden removal of the pressure of the contents of
the gravid uterus upon the abdominal viscera and large vessels of
the body. Females of a despondent or gloomy state of mind, or
who are apprehensive concerning the termination of their labor,
are also subject to it.

A prudent exhibition of Wine, Ether, Ammonia, or other stimu-
lants, to invigorate the energies of the system, with moderate
warmth, fresh air, depression of the head and shoulders, a spriuk-
ling of Ammonia or Camphor upon the face and neck, and fric-
tions to the extremities, will commonly be sufficient to restore the
patient. Of course, when the symptom happens from organic
difficulty, the probability of rallying the female will depend upon
the character of the disease. When it occurs after the delivery,
in addition to the above means, apply friction to the abdomen,
together with a broad bandage firmly and properly applied.

COMPLICATED LABOR — THROMBUS.

525

Sometimes an extravasation of blood into one or both of the
labia pudendi, suddenly occurs during labor, or shortly after the
birth of the child, which is termed THROMBUS. It is the result
of a rupture of varicose veins of the vagina, or of some of the
large bloodvessels.

The effected labia present the appearance of a livid or black
tumor, of greater or less size, frequently as large as the head of a
child, being accompanied with intense pain.

Dr. Dewees states, that if the inner surface of the attacked lab-
ium does not burst in the first instance, the tumor is certain to
yield in a short time from gangrene. A large surface of coagu-
lated blood becomes exposed when the part sloughs, which rapidly
decomposes and becomes fetid. If the parts do not rupture, the
patient suffers most excruciating pain: active fever takes place
with delirium, and her life becomes seriously endangered. A
retention of urine increases her sufferings, and relief can only be
obtained by making a free incision on the mucous face of the lab-
ium, to allow the extravasated blood to escape, and which should
be done before the process of ulceration has commenced, or the
chance of bursting. Then press the enlarged labium to one side*
and evacuate the bladder by means of the catheter.

Thrombus is most commonly present in cases of protracted labor
caused by pelvic deformity, and generally proves fatal, especially if
not attended to at an early period. Sometimes its progress is very
rapid, the blood effused being so great in quantity as to cause syn-
cope; or the mucous membrane may rupture, followed by a cessa-
tion of pain, and a hemorrhage, which may be so excessive as to
rapidly destroy the patient.

These tumors must not be confounded with inversion of the ute-
rus, or of the vagina, or with cystocele, vaginal hernia, etc.

TREATMENT.— If this difficulty happens during labor, and the
tumor interferes with the passage of the head, it should be freely
incised on the mucous surface (the extent of the incision being in
proportion to the size of the swelling), and the fluid allowed to
escape. Should it be, however, excessive in quantity, too great a
discharge must be checked by applications of cold, ice, and compres-
sion, which must be continued until the engagement of the head,
by pressing upon the ruptured vessels, prevents any further flow.

If the thrombus occurs during pregnancy, or after delivery, with
only a small tumor, but little discoloration of the skin, and no
perceptible increase of the effusion, and no fluctuation, attempts

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AMERICAN ECLECTIC OBSTETRICS.

should be made to resolve it, by the application to the parts, of
cataplasms of Elm and Arnica flowers, or Elm and flowers of St.
Johnswort, aided by warm fomentations to the hands, feet, and
legs. And the same course may be pursued after delivery, when
the tumor ceases to enlarge, carefully watching, however, and
opening it, upon the first appearance of inflammatory symptoms.

If the tumor continues to increase, with debility and sinking of
the system, incise it, as before named, evacuate at least the greater
part of the clots present, by the fingers, and then make firm and
permanent compression upon the whole tumor, together with
applications of ice, if the effusion does not readily cease.

Always sustain the strength of the patient by appropriate stim-
uli, nourishing diet, etc.; and keep down febrile symptoms by the
solution of Acetate of Ammonia and Morphia (See Am. Disp., page
1047), or by the remedies usually exhibited for this purpose. Keep
the bowels regular, enjoin quiet, the recumbent position, and clean-
liness of the parts, and do not suffer the bladder to become over-
distended with urine. The tincture of Gelseminum, with a small
proportion of the tincture of Aconite root added, will prevent any
subsequent attack of erysipelas, or peritoneal inflammation, in
many instances.

CHAPTER XL.

COMPLICATED LABOR. PUERPERAL CONVULSIONS ECLAMPSIA HYSTERICAL CONVUL-
SIONS— APOPLEXY EPILEPSY.

One of the most dangerous and frightful maladies with which the
puerperal female may be attacked, is CONVULSIONS (Eclampsia
puerperalis). It usually occurs during labor, though occasionally
met with for some time previously, but seldom before the sixth
month of pregnancy; and it frequently manifests itself after
delivery, when it is of a more favorable character.

According to statistics, it is fortunately a rare disorder, having
occurred in 172 cases of labor, out of 103,537; or about 1 in 602.
Primiparse are more subject to it; instances, however, have pre-
aented of multipart who were attacked by it in their tenth or
twelfth labors. The fatality of the mother, heretofore, has been
about one in every four; most commonly the children are still-
born. Females with short, thick necks, of low stature, and square

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 527

form, and of a sanguine temperament, are considered to be more
subject to it — yet none are entirely exempt from it. It frequently
attacks those who, in early life, suffered from epilepsy, hysteria, or
who have received injuries of the head.

Beside the true puerperal convulsions, there are three other vari-
eties which may attack the parturient female, viz. : the hysteric,
the apoplectic, and the epileptic, each of which will require a sepa-
rate notice.

Hysteric Convulsions, with their treatment, have been referred
to under the diseases of pregnancy (see page 155). It maybe
proper, however, to name the distinguishing marks between these
and the true puerperal convulsions.

IN HYSTERIC CONVULSIONS.

1. Consciousness may, or may not be en-
tirely lost ; generally the insensibility is
incomplete.

2. The spasmodic action is moderate, the
body being but slightly contorted.

3. No frothing at the mouth, and no
biting the tongue.

4. The breathing is not stertorous nor
hissing.

5. The convulsive attacks are not fre-
quent, the patient recovering shortly after
each.

6. There may be sobbing, sighing, weep-
ing, and screaming.

IN PUERPERAL CONVULSIONS.

1. Consciousness is completely lost.

2. The spasmodic action is violent, with
powerful and irregular agitation of the
muscular system.

3. Frothing at the mouth, with biting of
the tongue.

4. The breathing is rapid and violent,
with a loud, peculiar, hissing sound.

5. The paroxysms are frequent, with to-
tal insensibility, or incomplete conscious-
ness during the intervals.

6. Sobbing, sighing, weeping and scream-
ing, are never present.

Apoplectic Convulsions, when present, almost always occur
toward the termination of labor; and are caused by the pressure
exerted upon the cerebral vessels during the contractions of the
uterus. They are rarely met with, and most usually prove fatal.

Sometimes no premonitory symptoms will be present; at others,
there will be pain, and throbbing, with other disturbance of the
head, for several days previously. During labor, there will usually
be more or less headache, and in the expulsive stage, the counte-
nance will be flushed, with a fullness of the vessels of the eyes.
There will be some agitation of the limbs and body, with but little
spasmodic action ; seldom any distortion of the face, no frothing
at the mouth ; the pulse is full and slow, and the pupils fixed, and
either contracted or dilated, and insensible to light. The breathing
is stertorous ; the muscles soon become flaccid and powerless ; the

528

AMERICAN ECLECTIC OBSTETRICS.

patient lies in a comatose condition, and very rarely has a second
paroxysm.

Tie following are the marks of discrimination between these
and the true puerperal convulsions:

IN APOPLECTIC CONVULSIONS. IN PUERPERAL CONVULSIONS.

1. The convulsive movements at the com- 1. The convulsions are violent and are
mencement are slight, and are not repeated, repeated, with intervals of quiet, and
the unconsciousness being persistent, often a more or less complete return to
Sense and sensibility are completely lost. consciousness.

2. The breathing is stertorous. 2. The breathing is violent, with a loud,

hissing sound.

3. The muscles become flaccid and pow- 3. The muscles preserve their tone, even
erless. during the intervals.

PATHOLOGY. — The brain will occasionally be found much con-
gested, without effusion ; sometimes, the pressure of a great effusion
of serum causes the attack ; more commonly, blood is poured out
into the ventricles, into the substance of the brain, or at its base.
It is almost impossible to distinguish the congestive form from that
caused by effusion ; the principal difference exists in the intensity of
the symptoms. {Churchill.)

TREATMENT. — Prompt and energetic measures can alone be of
service in these cases. Cold water, or ice should be applied to the
head and neck, a brisk purgative enema, to empty the lower bowels,
should be given as soon as it can be prepared, and warmth and fric-
tion should be applied to the inferior extremities and lower half of
the trunk. In the application of the water,- the head should be
withdrawn carefully from the bed, and held over some large vessel
to receive the fluid after it has been poured on. If the attack
occurs during labor, the delivery should be hastened as speedily as
may be done with propriety, but always without force or rudeness.

The above measures should be persisted in for some time. If a
return to consciousness follows, administer a purgative as soon as
the patient can swallow, apply warmth and counter-irritation to the
extremities, and keep the head cool. Always be certain that the
bladder is evacuated, and does not become distended.

Epileptic Convulsions do not vary in their symptoms and treat-
ment from those of ordinary epilepsy ; they very rarely occur with
parturient females, unless they have had previous attacks, and are
subjects of the disease. But epileptic females are not more liable to
puerperal convulsions than others. The symptoms of epilepsy so
much resemble those of eclampsia, that it would be impossible to

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 529

distinguish between them in the parturient female, unless we were
apprised of the fact that she had previously been subject to epileptic
attacks. And even then, our diagnosis might be incorrect, for the
reason that an attack of epilepsy, occurring at this time, might be
converted into a true eclampsia. As epilepsy may, however, when
manifested during labor, be mistaken for the true puerperal con-
vulsions, it may be proper to name some of the marks of discrim-
ination between them.

IN EPILEPTIC CONVULSIONS. IN PUERPERAL CONVULSIONS.

1. The aura epileptica is observed. 1. The aura epileptica is never observed.

2. There is usually but one paroxysm; 2. There are almost always several par-
or where there are several, they do not sue- oxysms, rapidly following each other,
ceed each other rapidly.

3. The patient has generally had previ- 3. The patient has never been attacked
ous attacks. with epilepsy before.

True puerperal convulsions appear to partake both of the nature
of epilepsy and apoplexy, and are considered by many eminent
writers as veritable apoplexy with violent spasmodic paroxysms
superadded, the latter being occasioned by the great degree of
nervous excitability to which all pregnant and parturient females
are liable.

The causes of puerperal convulsions are not well understood.
Plethora, compression of the aorta, long-continued mental excite-
ment, highly electrical conditions of the atmosphere, persistent damp,
foggy weather, and previous diseases or injuries of the head, have
been variously named as predisposing causes. Females, not married,
who do not enjoy the pleasures of society, and particularly who are
given to the use of liquors, are especially liable to it. It has also
been supposed, that a retention of urea, occurring, either from the
presence of Bright's disease, or from pressure upon the emulgent
veins by temporary congestion upon the kidney, has occasioned the
paroxysms. According to Dr. Lever, albuminous urine and puer-
peral convulsions are frequently met with together, very few cases
of the latter occurring which do not give evidences of the presence
of albumen.

Twins, excess of the amniotic fluid, death of the child, distension
of the bladder, irritation of some part of the alimentary tube, indi-
gestible food, severe labor-pains, rigidity of the os uteri, irritation
of the uterine nerves by the introduction of the hand, terror, or vio-
lent mental impressions, etc., have all been viewed as exciting
causes. Most probably, however, the nervous system of some organ,

530

AMERICAN ECLECTIC OBSTETRICS.

as the uterus, stomach, bladder, etc., transmits the irritation, which
has been occasioned by some derangement of its functions, to the
spinal system and the brain.

According to Churchill, Dr. Tyler Smith, "has proved that con-
vulsions are not excited by irritation of the cerebrum alone, but by
the primary or secondary effects produced upon the spinal marrow,
medulla oblongata, or tubercula quadrigemina. And therefore that
the causes giving rise to convulsions may be either, 1, Centric, such
as pressure on the medulla oblongata from congestion, coagula, or
serous effusion within the cranium; loss of blood, morbid elements
in the blood; emotion. Or, 2, Eccentric, acting on the extremities
of the excitor nerves, as irritation of the incident spinal nerves of
the uterus and uterine passages; irritation of the excitor nerves
within the cranium; irritation of the incidental spinal nerves of
the rectum; irritation of the ovarian nerves; irritation of the
gastric and intestinal branches of the pneu mo-gastric nerve; irri-
tation of the incidental spinal nerves of the bladder ; and as prob-
able causes, irritation of the cutaneous nerves, of the nerves of the
mamma?, and of the hepatic and renal branches of the pneumo-
gastric. More than one of these causes may, of course, act at the
same time."

Although all females are liable to attacks of this disease, yet
those who labor under any of the following conditions, are sup-
posed to be more disposed to it, and such should, therefore, receive
the earliest attention of the medical man, in order to prevent its
attack; corpulent females; those having short necks; those haying
firm, solid, unyielding tissues, or who possess great muscular
strength; those whose feet and hands swell, and who experience a
numbness in the hands, or in the limbs, with swelling of the face*
on awaking every morning; those who feel excessively weak, or
who labor under partial or complete loss of sensation in one side
of the face, or limbs; those who are subject to headache, dizziness,
muscse volitantes, dimness of sight, double vision, seeing only one
half of an object, or flashes of light within the eyes; those who
experience loud noises in the ears, especially when occurring sud-
denly, or who feel as if the head had received a violent blow.
Anremic females should receive especial attention.

The proper course by which to prevent an attack in such females,
is to keep the bowels and kidneys regular by laxatives and mild
diuretics; attend to the surface by occasional bathings, with fric-
tions and the use of a proper amount of clothing; regulate the

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 531

diet, that it be nourishing, but not gross nor too stimulating, and
agrees with the stomach,' readily undergoing digestion. Exercise
moderately but regularly in the open air, and have all sources of
mental anxiety or agitation removed. In addition to these
measures, strengthen the uterine nervous system by the exhibition
of the compound syrup of Partridgeberry, the compound pills of
High Cranberry, compound pills of Black Cohosh, compound pills
of Ferro-cyanuret of Iron, or compound pills of Motherwort, as
may appear the best adapted to each particular patient. The
syrup, first named, will be found applicable to the greater number of
cases. Small doses of some chalybeate preparation should be given,
in conjunction, to ansemic patients. If there are serous infiltra-
tions, diuretics may be given, as Polytrichum juuiperum, Althaea
officinalis, Apium petroselinum, etc., with saline draughts, as Seid-
litz powders.

SYMPTOMS. — The most violent puerperal convulsions may
take place without any premonitory symptoms ; but in the majority
of cases they will be met with. For several days previously, or
perhaps for only an hour or two, the patient will complain of more
or less severe headache ; giddiness ; dazzling of the eyes ; weight
and constriction across the forehead; beating of the temporal
arteries; disturbance of the sight and hearing, or, perhaps, a sud-
den loss of sight; ringing in the ears; rigors; flushed counte-
nance; stammering, or incoherency of speech; confused thought
or memory, slight delirium, and other indications of cerebral dis-
turbance. Occasionally, pains will be felt in the region of the
stomach. One or more of these symptoms are premonitory warn-
ings of an attack, and when they exist, demand prompt attention
from the accoucheur, who must at once endeavor to prevent the
paroxysms by appropriate measures.

No relief being had, the symptoms become aggravated until the
attack occurs. The face now becomes more flushed and swollen,
the eyes fixed, and the pupils dilated; though occasionally cases
will be met with, in which the pupils contract closely. The
patient rapidly becomes unconscious. The voluntary muscles of
the system become violently and irregularly convulsed. The head
is rotated by jerks from right to left, or backward, and the limbs
are thrown with spasmodic violence in every direction, requiring
powerful efforts to keep the female in bed. The muscles of the
face are commonly affected first ; the eyes roll rapidly about, being
frequently thrown upward and inward to the root of the nose, and

532

AMERICAN ECLECTIC OBSTETRICS.

irregular convulsive twitchings may be observed about the mouth
and eyelids. The lower jaw becomes firmly and spasmodically
closed against the upper, or it may be drawn to one side. The
tongue is involuntarily protruded, and is generally of a livid color,
and if some care be not taken, the spasmodic closure of the jaws
will severely wound it, so that the frothy saliva which is blown
from the mouth, sometimes to a considerable distance, will be
tinged with more or less blood; this may be frequently prevented
by placing a cork between the teeth, as soon as they become sepa-
rated. The breathing is rapid, irregular, and violent, and is
accompanied with a loud, peculiar hissing sound, owing to the
presence of froth and the compression of the lips and teeth. The
pulse varies, but is generally quick, full, and hard, at the com-
mencement, but finally becomes slow and hardly perceptible. The
face is distorted by the spasmodic contractions, and becomes turgid
and livid, and in which color the hands, and feet, as well as the
body, participate. Frequently the contents of the bladder and
rectum are involuntarily evacuated.

Occasionally, the muscles of one side of the face and body are
only convulsed, but, as the spasms cease, those of the opposite side
become affected.

After a certain length of time, varying from a few minutes to
half an hour, the violence of the convulsive motions diminish and
gradually cease altogether ; the features begin to appear more
natural, the pulse is still quick but more readily discernible, restor-
ation of the circulation takes place, and the breathing becomes
more regular. Consciousness slowly returns in a greater or less
degree; the female, awakening, apparently, as if from a sleep,
may be aware that something uncommon has occurred, or, as is
more generally the case, she may have no recollection whatever,
her mind being more or less confused. Pain in the head is nearly
always complained of. After an interval of quiet, varying from
fifteen minutes to two or three hours, the paroxysms return, when
the same phenomena take place as before, followed b}T another
interval; and thus the paroxysms and intermissions follow each
other, until they cease entirely. I met with one female, in my
early practice, who had sixteen paroxysms in as many hours.
Very frequently, in these convulsions, the consciousness returns
very slowly, and immediately upon its first manifestation, a
paroxysm comes on.

Consciousness does not, however, return in all cases ; not unfre-

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 533

quenlly the patient, during the intervals, remains motionless
and insensible, with stertorous, or hissing respiration, somewhat
resembling coma or asphyxia, and which may soon prove fatal ; or,
she may be unconscious and restless, throwing herself about in the
bed, until the next convulsive paroxysm.

Most commonly the duration of the convulsion does not exceed
five or ten minutes, while the intervals may extend to even twelve
hours in some cases, and but a few minutes in others.

W hen convulsions occur in the pregnant female, it is seldom
that she will complete the full term, and the child will be still-
born, and frequently putrid ; probably, the paroxysms may at
times be caused by the dead child acting as a foreign irritant to
the uterus, its death having taken place previous to the attack.
Occasionally, the spasms cease spontaneously, without endangering
pregnancy ; but more frequently, uterine contractions are aroused,
which generally expel the child, and this may happen without any
consciousness on the part of the mother.

If the convulsions come on before the occurrence of labor pains,
at the full period, they usually cause dilatation of the os uteri; and
the uterine contractions which may follow, will be feeble, irregular,
and apparently spasmodic, often alternating with the convulsive
paroxysms.

During labor, there may or may not be a suspension of the con-
tractions of the uterus ; but more commonly it participates in the
general spasmodic irritability, and contracts powerfully, effecting
delivery without the patient being aware of it. The paroxysm
usually ensues just upon the return of uterine action, though not
always with each pain. Generally, the ordinary character of the
pains are not changed by the convulsions, and the labor proceeds
regularly, unless hastened by art. Not unfrequently, however, the
action of the uterus becomes inefficient, and the delivery must be
artificially completed.

"When puerperal convulsions occur during labor, they most fre-
quently cease when delivery is effected, or soon after, unless they
prove fatal; and the patient is generally left with a strong ten-
dency to metritis and peritonitis.

Puerperal convulsions may terminate by recovery ; by develop-
ing some other disease, as paralysis, cerebral lesions, mania,
epilepsy, rupture of the uterus, metritis, peritonitis, etc. ; or, by
death.

The recovery may take place rapidly, especially when the parox

534 AMERICAN ECLECTIC OBSTETRICS.

ysms have been few and of a mild character ; or, it may be tedious
and for a long time uncertain ; the intellectual faculties very grad-
ually returning to their normal condition, the memory being
excessively debilitated, or destroyed, as well as the hearing and
sight. This derangement may continue for a day or two, or may
extend to several months before complete restoration takes place.

"When other diseases are occasioned by the convulsions, the
patient may ultimately recover, but generally with impaired health
for the remainder of her life ; and frequently these diseases con-
tribute to a more or less speedy fatality. Death most usually
occurs when the paroxysms are of great intensity and long dura-
tion, with short intervals between them, and especially in those
cases where the female remains motionless and unconscious during
the intermissions. It may be caused by effusion on the brain, or
by a too prolonged and complete suspension of respiration ; also
by a rupture of the uterus.

The above description of symptoms, together with the pre-
ceding tables for distinguishing the attack from hysteria, apoplexy,
and epilepsy, will render it unnecessary to detail any further
diagnosis.

PROGNOSIS.— This is undoubtedly an extremely fatal disease,
the most favorable statistics showing that one-fourth of those who
have been attacked by it were lost. But the practitioner may gen-
erally be enabled to form a prognosis, somewhat approximating
positiveness, by ascertaining the cause that produced the attack,
and by observing the period at which it occurs, and the progress
and character of the symptoms.

If the paroxysms are very severe and of long duration, the inter-
vals being short, and no return of consciousness; the patient lying
in a state of stupor with stertorous breathing, she will be in a very
critical situation, and more especially if she be insensible to the
application of stimulants. The longer the duration of the inter-
vals, and the more perfect and rapid the return of consciousness,
the more favorable will be the case, notwithstanding the severity
of the paroxysms. And the milder the convulsions, with the last-
named character of intervals, the less will be the danger.

Females whose nervous systems are extremely susceptible, who
are hysterical or subjects of epilepsy, or whose minds are very
sensitive, are less apt to have formidable attacks, than those who
are disposed to apoplexy, or coma, or who are laboring under
serous infiltrations.

COMPLICATED LABOR — PUERPERAL CONVULSIONS.

535

Convulsions occurring during pregnancy, or during labor, are
more dangerous then those which take place only after delivery ;
and when they occur early in labor, before the parts are sufficiently
dilated to admit of the ready expulsion of the uterine contents,
they are less favorable than toward the termination of the deliv-
ery, when this may be effected either naturally or artificially. They
are likewise more fatal among primiparse.

"When the convulsions come on during the last stage of labor,
and continue equally strong after the deliver}-, whether this has
been effected naturally or artificially, the case is extremely danger-
ous; but if the patient falls into a gentle sleep, with an arrest of
the paroxysms, after the expulsion of the uterine contents, they
seldom return, and convalescence ensues. After the delivery and
the disappearance of the convulsions, the practitioner must care-
fully watch the patient in order to guard her against any subse-
quent abdominal inflammations, more especially if puerperal peri-
tonitis be, at the time, a prevailing complaint.

The maternal disorder necessarily exerts an unfavorable influ-
ence upon the child, and we find that the major part are either
still-born, or die in a few days after birth, of convulsions, having,
probably, while in utero, received the germ of the disease through
the mother's blood.

PATHOLOGY. — Post-mortem examinations have shed but
little light upon the nature of puerperal convulsions, no apprecia-
ble anatomical lesions having been found — no traces of injection
nor changes in the characters of the tissues.

Sometimes a serous effusion has been observed in the ventricles,
or arachnoid cavity, and perhaps a slight congestion of the enceph-
alic vessels — but these are viewed as secondary lesions, being
merely the effects of the convulsions, when the cerebral conges-
tion is very great. The heart is commonly empty and relaxed,
the lungs pale, and occasionally, fluid has been met with in the
pleura, or pericardium ; traces of peritoneal inflammation have
likewise been observed.

TREATMENT. — The indications of treatment in puerperal
convulsions, are 1st, to subdue spasmodic action ; 2d, to overcome
cerebral congestion, and equalize the circulation ; 3d, to hasten
the delivery, when labor is on, by the most appropriate means,
provided the paroxysms are not subdued ; and 4th, to prevent any
secondary attacks, and gradually strengthen the patient.

For the fulfilling of theifirst indication, bleeding to the amount

536

AMERICAN ECLECTIC OBSTETRICS.

of from thirty to sixty ounces, and taken in a full stream from the
arm or temporal artery, has been recommended; indeed it is the
remedy, and the principal remedy upon which the majority of prac-
titioners rely. In former years I was in the habit of bleeding in
these cases, and with varions results, but I am now thoroughly
convinced that many of the unsuccessful cases could have been
saved by different treatment, and that, in the successful ones, the
bleeding effected but very little service. Indeed, what benefit can
any thinking man consider to be the consequence of excessive
bleeding, when, at farthest, but only one out of every four patients
is saved ? Beside, those who are saved by these excessive deple-
tions, rarely have a complete restoration to health subsequently, but
linger for a longer or shorter time, under some malady resulting
from the bleeding, and which ultimately occasions their death.
These large bleedings seriously injure the vital force, and, I believe,
frequently prevent recovery where it might otherwise have taken
place. The treatment which I shall now recommend to the pro-
fession, in puerperal convulsions, will be found fully as successful
as the depletive one just referred to, and vastly superior to it, inas-
much as it does not cause any serious affections from sudden,
excessive, and persistent prostration of the vascular and nervous
systems.

For the accomplishment of the first indication above named, one
of two articles may be exhibited to the patient, viz.: the tincture
of Gelseminum, or the compound tincture of Lobelia and Capsicum.
The tincture of Gelseminum employed, must be a good article,
must be made from the fresh root, and kept free from exposure, in
well-stopped bottles. As the active principle of this agent depends
upon a volatile constituent, any concentrated preparation, as Gel-
semin, is worse than useless, because of the delay of proper meas-
ures when this is given, vainly trusting to its efficiency. I have
become acquainted with several instances in which a want of suc-
cess from the use of this tincture was owing entirely to its inertness,
caused by exposure or mal -preparation. It is a valuable agent,
and to be cast aside as inefficient or uncertain, from an ignorance
of the above circumstances, would be a very regretful matter to the
profession. The dose of the tincture must be proportioned to the
severity of the paroxysms ; if mild, one or two fluidrachms may be
given ; if severe, half a fluidounce. The dose should be repeated in
ten or fifteen minutes, during the intervals, after which a longer
delay may be had in giving the third dose, according to the severity

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 537

of the convulsions, and the duration of the intervals — not adminis-
tering it so often when the intervals are of considerable length.

If the patient is in a state of coma during the intervals, it will
be difficult to cause her to swallow, still this may be accomplished
by carefully watching for the proper moment; but if it be impos-
sible to get any of this tincture into her stomach, the compound
tincture of Lobelia and Capsicum, above named, must be substi-
tuted.

The use of this tincture must be continued in this manner, until
it has exerted a positive influence upon the muscular system of the
patient, rendering it powerless, when its further exhibition will not
be required, unless there be a return of the paroxysms. However,
the patient should always be placed under its relaxing influence as
soon as practicable.

Frequently, this agent will not only overcome the spasmodic
tendency of the voluntary muscles, but will at once relieve cerebral
congestion, favor the dilation of the os uteri and thus aid in hast-
ening delivery when labor is on, and also prevent any disposition
to subsequent abdominal inflammations.

The compound tincture of Lobelia and Capsicum may be given
in half fluidounce doses, repeated every ten or fifteen minutes. It
does not produce so great a degree of muscular relaxation as the
Gelseminum, but has a greater antispasmodic influence, and which
is generally manifested much sooner. In some respects it is supe-
rior to that agent — thus, it may be given during the paroxysms
with advantage, which is not the case with the other, at least as
far as my experience goes — beside, should the female have eaten a
hearty meal immediately previous to the attack, it will occasion
emesis, and thus relieve the stomach, without a loss of its other
influences upon the system.

Usually, it is impossible for the patient to swallow a single drop
of fluid while the fit is on, but if the little finger be placed in one
corner of her mouth and the lips be drawn outwardly, so as to
admit the practitioner to pour in, gradually, the above compound
tincture, it will be certain to reach the stomach — or, at least, the
greater portion of it will. The same result will ensue when the
patient lies in a comatose condition.

A paroxysm may be frequently shortened in its duration, by the
exhibition of this tincture while it is on; and its administration at
this time, does not contra-iudicate, nor interfere with the employ -
35

/

538 AMERICAN ECLECTIC OBSTETRICS.

ment of the tincture of Gelsemiimm during the intervals, should
this be deemed necessary.

The practitioner must take advantage of the depression of the
lower jaw at the commencement of each paroxysm, to insert a piece
of cork, or a roll of muslin, linen, or leather, between the molar
teeth, for the purpose of protecting the tongue from injury, and
which should be kept in its place by an assistant. He should also
remove everything, against which she might throw herself and
produce some harm.

For the second indication, various measures are required. The
bowels should be emptied by an injection as speedily as possible,
and for this purpose I prefer a mixture of warm Water, Molasses,
each half a pint, and Salt two drachms, to which a fluidounce of
the compound tincture of Lobelia and Capsicum is added. This
injection should be repeated occasionally, until a free and copious
alvine evacuation has been produced, after which, if the continu-
ance of the convulsions renders it necessary, half a fluidounce of
the above compound tincture, very slightly diluted with warm
water, may be injected, and repeated from time to time as the
urgency of the symptoms require. Used in this manner, the tinc-
ture exerts considerable relaxing and antispasmodic influence upon
the system.

For the purpose of facilitating the action of the bowels, it has
been advised to place a few drops of Croton Oil, rubbed up with a
little sugar, sugar of milk, or butter, upon the tongue — and which
may be repeated within a reasonable interval, if the first dose fails
to accomplish the cathartic result. This will often be beneficial;
but it is always desirable to obtain these copious evacuations from
the bowels at as early a period as possible; and the greater
the degree of cerebral turgescence, the more active must be the
catharsis.

Counter-irritation must be applied to the feet and extremities,
especially where the patient is comatose. The whole of the infe-
rior extremities should be enveloped in mustard, carefully watching
that it produces only its rubefacient effect, after which it must be
removed, and the feet and limbs wrapped up in flannel wet with
the following compound, and applied as warm as can be borne:
Spirits, Vinegar, of each half a pint, Capsicum four drachms,
extract of Stramonium two drachms, mix and warm it. This
should also be applied on flannel to the back and along the whole
length of the spinal column. Cloths wet with a strong infusion

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 539

of Lobelia and Stramonium leaves, should be applied over the
whole abdomen, and especially over the hypogastric region, as hot
as may be deemed sufficient, so that the skin be not scalded, and
these should be changed frequently. These last measures of coun-
ter-irritation and fomentations must be continued during the inter-
vals as well as in the paroxysms.

A most important part of the treatment in accomplishing the
second indication, and which must never be omitted, is the cold
douche, but which is to be used only during the paroxysms, or
during the intervals when the patient is comatose. Having the head
and shoulders drawn beyond the edge of the bed, and sustained
there by one or two bystanders, place a tub or some large vessel
beneath to catch the water, which must be poured, quite cold,
upon the head and neck of the patient, and this should be contin-
ued until two or three pailfuls have been used, or until the features
shrink. Then replace her in the bed, with the head and shoulders
elevated, and, if necessary, apply ice or cold water to the head,
until it is deemed proper to repeat the cold douche. This must be
resolutely persisted in, until the action of the cerebral vessels
becomes diminished, and their congested condition relieved.

During the intervals, when the patient becomes wholly or even
partly conscious, and the cerebral congestion has been somewhat
overcome, ligatures may be applied around the thighs, for the pur-
pose of preventing too much blood from being thrown into the
trunk and head. This will answer a much better purpose than
bleeding, as it does not withdraw any of the vital fluid from the
system, but some care must be observed that they are not allowed
to remain on too long.

Perhaps, cups to the head, nape of the neck, and lumbar region,
which have been advised by some, may be advantageously employed,
but they can not be readily applied during the paroxysms, and
during the intervals I would prefer the means already named. I
have never used cups in this disease.

All these means may not be required in every instance, but when
the convulsions are intense, with excessive cerebral congestion, they
should all be promptly, energetically, and persistently brought to
bear upon the disease ; and it must be truly a desperate case, which
can not be overcome by their timely application. Of course, no
cure can be expected where there is considerable effusion on the
brain ; but as we can not determine with positiveness whether this

540

AMERICAN ECLECTIC OBSTETRICS.

has occurred or not, we should be persevering in our efforts, how-
ever hopeless the case may appear.

During the continuance of the attack, the bladder should be
attended to, and evacuated by the catheter on the occurrence of an
interval, if it becomes too much distended ; and after the delivery
of the child, be careful that the placenta is not retained.

The third indication obtains only when the treatment fails to over-
come the disease. Frequently, during labor, when the child is
delivered, the convulsions cease, and from a knowledge of this fact,
some writers have recommended the hastening of the delivery, even
when the os uteri and other conditions present are not sufficiently
advanced for that purpose: and the consequence has been, that more
females have been destroyed by officious and forcible delivery, than
have been lost by leaving them to the natural resources of the sys-
tem. "It is far better that the woman should die convulsed in the
hands of nature, than that she should perish by the cruel and sav-
age operation of rough and unskillful midwifery." — (Blundell.)

When the accoucheur has faithfully employed the various means
recommended for the removal of puerperal convulsions during
labor, and no favorable impression has been made upon them after
a reasonable time has progressed, he may then ascertain whether the
condition of the parts are favorable for an artificial delivery : indeed,
it is proper for him to examine from time to time while the fits last,
lest the child be expelled unconsciously; also, to learn how the labor
is progressing, and what may be the influence exerted upon it by
the spasms. But he must be extremely cautious how he interferes
with the delivery, lest his attempts prove more fatal than the dis-
ease. It is not always that the evacuation of the uterus is followed
by a cessation of the convulsions; and not unfrequently these
become aggravated by the attempts made to hasten the labor.
When the female manifests periodically much uneasiness, moaning,
and groping and writhing about, it is indicative of uterine contrac-
tions taking place: and when the head is at the perineum, she will
frequently be observed to strain.

In a case where interference is indicated by the severity of the
attack and its unyielding character, if the os uteri be found rigid, or
soft and dilatable, but not fully dilated, the accoucheur must posi-
tively make no attempts either at aiding dilatation nor at rupturing
the membranes : he must wait — he must be patient, until complete
dilatation is nearly accomplished, when he may rupture the mem-
branes— a course which frequently expedites the labor; but he must

COMPLICATED LABOR — PUERPERAL CONVULSIONS.

541

not attempt turning, even should it be a breech presentation : turn-
ing is a very hazardous measure in convulsions, but few females
having recovered where it has been performed. Mal-presentations,
according to the observations of accoucheurs, are very rarely met
with in puerperal convulsions. If, however, the head be found in
the pelvis, and within reach of the forceps, and the instrument can
be readily applied without injury to the patient, the delivery maybe
terminated by it. But no attempts at artificial delivery must be
made while the paroxysms are on, unless the patient lies in a motion-
less and comatose condition; else, irreparable injury to the soft
parts may accrue, owing to the violent struggles of the patient:
and should a fit come on during the application of the blades, they
must be immediately withdrawn, to avoid being forced through the
walls of the vagina or uterus.

If the head be found steadily advancing, without any delay in its
progress, artificial aid is not required, no matter how intense and
obstinate the attack may be. Sometimes the head may be so firmly
fixed in the pelvis as to resist all justifiable efforts to remove it
with the forceps — here the perforator would be indicated ; but
unless the child is known to be dead, and there is a strong possi-
bility of benefit to the patient, it were better not to resort to it.
However, the judicious practitioner will be guided more by the cir-
cumstances of the case, than by any specific rules.

" Of 200 cases recorded, one-half were delivered by natural
efforts ; 22 died, or about 1 in 4|; of 35 delivered by the forceps,
13 died, or about 1 in 3 ; of 43 delivered by the perforator, 12 died,
or about 1 in 4 ; of 14 delivered by turning, 8 died, or about 1 in 2."

The fourth indication, to prevent any secondary attacks, and grad-
ually restore the tone of the system, is called for when the convul-
sions have ceased. Whatever may be the condition of the patient
at this time, whether she complains of pain in the head, or in the
abdomen, or whether she be maniacal, the apartment which she
occupies must be darkened, the greatest stillness must be observed,
and every source of irritation removed, that she may be kept as
quiet as possible. The lightest nourishment only should be per-
mitted, at first, as, mucilage of Gum Arabic, Barley water, Rice-
water ; afterward, as her strength improves, Sago, Arrowroot, and
weak Beef-tea, gradually increasing the diet as convalesence pro-
gresses. The bowels and bladder should be attended to, regulating
the former either by injections, or internal laxatives, as circum-

i

542 AMERICAN ECLECTIC OBSTETRICS.

Stances will allow. A proper management of the above measures
will be of more service than any medicines which may be given.

However, medicines will sometimes be required when distressing
symptoms, or symptoms indicative of some secondary attack, are
present ; among which the following have been advantageously
employed :

1. Take of extract of Belladonna six grains ; Morphia two grains;
sulphate of Quinia twelve grains — mix, and divide into six or
twelve powders, or pills, regulating the dose according to the sus-
ceptibility of the patient to its influence, and exhibit it three or
four times a day. In the severe headache, or mania, this will fre-
quently be of service.

2. Take of compound power of Ipecacuanha and Opium three
grains ; sulphate of Quinia one grain — mix for a dose, to be re-
peated two, three, or four times a day.

3. Take of extract of Belladonna, Musk, each six grains ; Camphor
three grains ; sulphate of Morphia from half a grain to a grain —
mix, and divide into six pills, of which one may be given three or
four times a day.

4. The tincture of Gelseminurn, combined with Sulphate of
Quinia, or with tincture of Aconite root, will likewise be found a
valuable remedy in removing these secondary attacks ; in many
instances proving superior to the preceding preparations.

Of course, though I have specified the doses above, the careful
practitioner will be guided in the administration of his remedies,
in all cases, according to their influence upon the system, and the
susceptibility of his patient, and never by any exclusive or arbi-
trary rules.

In the treatment of puerperal convulsions, inhalation of Ether,
and of Chloroform, has been highly recommended by several emi-
nent accoucheurs. I have never employed either in these cases
though not from any particular objections I have against their use,
but because I have succeeded without them. From self-experience,
therefore, I can say but little about their utility. Several practi-
tioners have informed me, that they exhibited Chloroform with suc-
cessful results ; and I know of two cases in which, from some cause,
it failed to produce any influence whatever. One of my former col-
leagues speaks favorably of it use, and has related to me a case in
which he kept a female partially, but continuously, under its influence
four and a half days, before the convulsive disposition was subdued.

COMPLICATED LABOR — PUERPERAL CONVULSIONS. 543

In the absence of the agents heretofore recommended, I should
not, under certain circumstances, hesitate to administer Ether, or
Chloroform ; but I think I would never employ either of them in
those cases where there were symptoms of very great cerebral con-
gestion, and especially where the patient remained in a state of
coma or stupor, during the intervals between the paroxysms.

Before closing this chapter, I would suggest, as a useful auxiliary
in the treatment, bastinadoing the soles of the feet. I have frequently
adopted this plan in apoplectic attacks, and in cases of great conges-
tion of the cerebral vessels, with marked success. It should be
done during the paroxysm, and also during the intervals when the
patient lies in a state of stupor, or coma. It may, at first sight,
appear a rough measure, but the life of a human being is at stake —
besides, it is less objectionable, and certainly more philosophical,
than to remove that fluid in large quantity which is so essential to
health and life — the blood.

I? A. R T IV.
OBSTETRICAL OPERATIONS.

CHAPTER XLI.

TURNING, OB VERSION. CEPHALIC VERSION PODALIC VERSION THE FILLET THE VEC-

TUS LEVER, OR TRACTOR BLUNT HOOK PLACENTAL FORCEPS.

All operations during labor, for the purpose of artificial delivery,
whether manual or instrumental, are necessarily accompanied with
more or less danger, and, hence, they should never be attempted,
for any purpose whatever, unless nature is found incompetent to
terminate the delivery, or, when absolutely required to preserve
the mother's life, or that of the child, when the mother is in
a hopeless situation.

The great sacrifice of health and life, among females, from indis-
criminate and unjustifiable interference, has led many practitioners
to set aside atl artificial means of relief, and to rely entirely on
unassisted nature, in every case of labor. This, however, is passing
into another extreme, and is decidedly wrong; aid is sometimes
demanded, and then it must be given — to withhold it would be
criminal ; and it is among these cases, in which the properly edu-
cated accoucheur distinguishes himself from the ignorant pre-
tender, by his calmness and prudence, his proper selection of the
time for affording assistance, as well as of the means to be used,
and the cautious and skillful employment of these means.

Let the student remember, that in no case are the efforts of
nature to be intermeddled with, either by manual or instrumental
operations, unless it be absolutely and positively known that they
are insufficient to complete labor. Prolapsus of the uterus, rupture
of the uterus, inversion of the uterus, profuse hemorrhage, perito-

TURNING, OR VERSION — PODALIC VERSION.

545

nitis, permanent dysmenorrhea, laceration of the vagina, and also
of the perineum, etc., have frequently resulted from ill-timed,
injudicious, and unwarrantable endeavors at forwarding the
delivery. These accidents have occurred in the practice of the
most eminent obstetricians in instances where the greatest care
and prudence were exhibited ; how much more readily then will
they happen in the practice of the ignorant, officious, and uncon-
scientious practitioner? Were females, or their husbands and
friends, generally aware of the great want of skill and knowledge
in this department of medicine, which prevails so extensively in
the profession, and which is based upon the fact, that in the
majority of labors the unassisted and natural resources of the sys-
tem are adequate to the task of completing labor, they would be
more careful and scrupulous in their selection of obstetric attend-
ants, and by this means would compel students to be more atten-
tive to the means of becoming efficient and skillful. I do not
refer merely to a want of knowledge and practice in labors actually
requiring assistance, but, more particularly to those in which no
aid is needed, and in which the practitioner destroys either health
or life, by vain and ignorant displays of unwarrantable manipu-
lations.

Among the operations occasionally required during labor, and
to which some reference has been made in the preceding pages,
that of TURNING or VERSION, may be noticed. According to
Churchill, 49,323 cases in English practice, required turning in 190
instances, or about 1 in 260; 37,479 cases in French practice,
required it in 400 instances, or about 1 in 93 J ; 21,516 cases in
German practice, required it in 337 instances, or about 1 in 64.
Making 927 cases of version out of 108,318, or about 1 in 117. In
192 cases, in which the mortality to the mother has been named,
12 died, or 1 in 16. In 565 cases, 187 children were lost, or nearly
1 in 3. Some allowance must be made, however, for the various
and serious accidents which render the operation necessary.

There are two modes of turning mentioned by writers ; one, the
CEPHALIC VERSION, or Version by the Head, in which the
head is brought to the pelvic brim; the other, PODALIC VER-
SION, or Turning by the Feet, in which delivery by the feet is sub-
stituted for that by the original presenting part.

CEPHALIC VERSION, has been recommended at various
times by eminent accoucheurs, but, heretofore, it has not proved
so efficacious as could be desired, and hence is not much practiced.

546

AMERICAN ECLECTIC OBSTETRICS.

It has been advised in mal-positions of the vertex, in face and ear
presentations, and sometimes in shoulder presentations ; but where
prompt delivery is demanded, turning by the feet is preferred. In
reply to objections, that it is difficult to seize the head firmly, and
bring1 it to the brim, Velpeau observes : "1st, it is not always very
difficult to seize the head, and to exert considerable force upon it ;
2dly, if the waters have not been long discharged, one may often
without difficulty seize the vertex, and bring it to the center of the
brim, however far it may have been distant; 3dly, that in general
it is better to force the head to descend, by pushing up the pre-
senting part, than by bringing down the head ; 4thly, that deliv-
ering by the breech is far from being a simple and safe operation;
as regards the child, it is less so than cephalic version, even if the
forceps should be afterward applied." Notwithstanding this reply,
there is much weight in the objections ; and attempts to push up
the presenting part will frequently induce such violent uterine
contractions as to cause the operator to desist. (See quotation from
Prof. Wright, page 434).

POD ALIO VERSION", or turning by the feet, is the operation
generally practiced and preferred in those cases where a change of
position, or prompt delivery is required. It possesses several
advantages as well as disadvantages. The advantages are, that the
accoucheur has the labor more completely under his control, and
can deliver or not, as the case may require, with or without uterine
action ; it is nearly equal, in point of safety, to vertex labors, and
is superior to any other; it is frequently the only method by which
to save the child's life, or to avoid exvisceration ; and often it is
the only chance for the safety of the mother. Its disadvantages
are, that the risk to the mother's life is always enhanced by an
introduction of the hand into the uterus; that it is sometimes very
difficult, if not impossible to effect it, and that the fatality to the
children is very great where it has been performed, about one in
three being lost.

The cases in which turning may be effected with advantage, are in
shoulder presentations; transverse presentations of the body; mal-
positions of the head; difficult breech labors; placenta prsevia;
hemorrhages; convulsions; prolapse of the cord; rupture of the
uterus; syncope; and whenever the mother's life is jeopardized.
It must not be forgotten, however, that turning is never to be
attempted when the head has passed through the brim into the
pelvic cavity; delivery must, in this case, be effected by the

TURNING, OR VERSION — PODALIC VERSION.

547

forceps, or perforator. When the head passes into the vagina, the
cervix will contract around the neck of the child, and it will then
be impossible to return it into the uterus. But when the head has
not completely passed beyond the os uteri and the superior strait
into the vagina, it may be pushed upward into the uterus, and ver-
sion may then be accomplished.

The most important point for the accoucheur to determine, is
the suitable time for the operation; a precipitate interference, or too
long a postponement, are equally fraught with danger. There
are, however, instances in which delivery by turning should be
promptly effected, and others, again, in which it should be
delayed.

Turning, when required, should always be accomplished as soon '
as possible, in placenta prsevia, in preternatural presentations, in
profuse hemorrhage, and whenever symptoms arise which threaten
the life of the mother or child, provided, in each instance, the os
uteri be soft, dilatable, and sufficiently dilated.

It should be delayed when the os uteri is rigid, or soft but not
sufficiently dilated; and, when the membranes have been long rup-
tured, the liquor amnii having entirely escaped, and the uterus
contracting powerfully upon the fetus.

At an early period of labor it is very difficult to detect a mal-
presentation, or a mal-position, although it may be suspected by
the shape of the protruding bag of waters, as heretofore men-
tioned (pages 406, 420) ; but, when the os uteri has nearly com-
pleted its dilatation, and more especially when the membranes
have ruptured, any preternatural presentation may be correctly
determined. And this period is always the most favorable for the
operation of the version. Should, however, a mal-presentation,
requiring turning before labor can be terminated, be detected
before the membranes have ruptured (as a shoulder presentation,
or placenta previa, etc.), the operator may attempt the version, as
soon as the state of the os uteri will permit the introduction of the
hand, without the employment of force ; in this case, as the hand
advances, the membranes become ruptured, the wrist and arm
prevent the liquor amnii from escaping, the uterus remains dis-
tended, and the turning is readily accomplished. But, although
prompt action of this kind is required in placenta prsevia, or hem-
orrhage, a delay, until the os uteri is fully dilated and the mem-
branes ruptured, does not necessarily occasion any greater risk in
a presentation of the shoulder.

548

AMERICAN ECLECTIC OBSTETRICS.

When the os uteri is rigid, or when, the waters having been
long discharged, the uterus contracts powerfully upon the fetus,
no attempts at introducing the hand must be made until the
rigidity has been overcome, or the irritable condition of the
uterus lessened by the means heretofore named, (pages 333 and
428.)

Turning has been advised as a substitute for the employment of
the perforator, in some cases of narrow or deformed pelvis; but,
from the dangers incident to the operation, and the difficulty in
correctly ascertaining the relative proportions between the fetal
head in utero and the pelvic diameters, it seems to me an infeasi-
ble plan. The risks to the mother must be greatly augmented
by the operation, while those to the child will be by no means
diminished.

The mode of performing podalic version, has already been de-
scribed on page 423; the principle of operation is about the same
in all cases. I will, therefore, at this place merely recapitulate.
Empty the bladder and rectum, the first more especially; place the
female on her back, with the hips brought a little over the edge of
the bed, her feet resting on two high stools, and properly sup-
ported. Protect the floor from the discharges. Select that hand
for the operation, whose palmar surface corresponds to the anterior
surface of the child's body. (If an arm presents, secure it by a
ribbon, in order to prevent its rising and interfering with the pas-
sage of the head.) The hand and arm must be oiled, and the for-
mer carefully introduced, in a conical form, within the vagina,
during a pain; it must be passed into the uterine cavity during the
absence of pain, while, at the same time, the external hand must
be placed on the abdomen, over the fundus, to support the uterus;
seize the child by the knee (hooking the finger in its flexure), or
by the feet, being careful that a foot and not a hand be grasped,
and turn the child during the absence of pain, bringing the inferior
extremities downward and over its front. If the limbs be brought
over the back of the child, the spine may, probably, be dislocated.
The traction must be gentle and continuous, and not by jerks or
forcible measures. Be careful to so manage the operation, that at
the last stage of the delivery, the face of the child will be in the
hollow of the sacrum. When the version is finished, replace the
female in the bed, and leave the delivery to nature; or, should it
be necessary to effect this artificially, wait for the uterine contrac-
tions and act in concert with them; for if the fractions be con-

TURNING, OR VERSION — PODALIC VERSION.

549

tinned, and the delivery completed without uterine action having
taken place, the sudden evacuation of the organ would be apt to
give rise to inertia, hemorrhage, or other difficulties. While the
hand is within the uterine cavity, should a pain come on, do not
present the knuckles for the organ to contract upon and run the
risk of rupture, but grasp the body of the child with the open
hand, removing it from the child's body, only when the pain has
ceased. When the uterus acts powerfully and vigorously, it inter-
feres with the introduction of the hand, as well as the detection of
the feet, and the version; and the operation becomes not only a
difficult one, but painful to both the physician and patient. The
operation is, however, comparatively an easy one, when the uterus
does not act with much force.

The hazards to which the mother is exposed in the accomplish-
ment of version, are, 1st, A rupture of the vagina, through, which
the fingers or hand of the operator may pass, and which may be
occasioned by the employment of too much force, omitting to sup-
port the fundus externally, or, a neglect in passing the hand in the
direction of the pelvic axes. 2d, If the search for the feet be con-
ducted rudely or forcibly, the hand may be driven through the
uterine walls. 3d, The hand of the operator, or the limbs of the
child may so bruise or injure the uterus as to occasion subsequent
inflammation; but this may arise independent of such injury. 4th,
The shock to the nervous system is usually more serious than in
natural labors of the vertex or breech.

The child may be destroyed by compression of the cord; or its
hip, or spine may be dislocated by forcible traction, or perhaps a
limb may be actually torn from it. It must be recollected, that
the cord commences being compressed at the period when the
nates emerge from the vulva; hence, the greater the delay in the
delivery after this time, the more dangerous is it for the child —
artificial respiration may be attempted, even while the head is in
the vagina.

Some writers recommend us to seize the hips and bring them to
the pelvic brim, but this is difficult and seldom attempted; others
advise, instead of searching for the feet to bring down the knees
when these are readily obtained; for the purpose of turning, I can
see no objection to this plan. As stated on a preceding page (425),
it is recommended to turn by one foot, instead of two, more espe-
cially on account of the increased dilatation of the soft parts, which
must follow, and thus afford greater facility for the expulsion of

550

AMERICAN ECLECTIC OBSTETRICS.

the head. Generally, this will be found to answer. According to
actual measurements, the circumference of the presenting portion
of the head, in labor, is from 12 to 13J inches; that of the breech,
with both thighs flexed upon the abdomen, is from 12 to 13-1- inches •
that of the breech, with only one thigh flexed, the other being
brought down, is from 11 to 12J inches; and that of the hips, both
legs being brought down, is from 10 to 11J inches. So that it is
much safer for the child, to accomplish version by one foot only.
I was called, a short time since, to a case where a foot and arm
protruded beyond the vulva, and no justifiable degree of traction
could move the child, neither was it possible to return the arm.
The waters had been discharged at an early period of the labor,
the uterus acted energetically, and the accoucheur had not been
able to find the other toot. Finally, after some attempts at chang-
ing the position of the fetus in utero had been made, he was ena-
bled to pass his hand upward, when he found the leg across and
at right angles with the presenting one; he carefully brought it
down, and the child was delivered in a few minutes. In this case
it would have been impossible to have effected the version by the
one foot.

After the delivery, do not place the child too soon to the breast,
but allow the mother a rest for some hours ; pursue the means
named on page 427, and be prompt to combat the first manifesta-
tions of inflammatory action.

The FILLET, is a strong piece of linen or ribbon, about three
inches in width, and twenty-five or thirty inches in length, and
has been recommended in breech labors, when the pains are not
sufficient to complete the delivery. Its mode of application is to
oil or grease it, and then, having rolled up some five or six inches
of one end, pass it into the vagina, and by means of the fingers
push it between the child's thigh and abdomen from one side to
the other ; then bring down the rolled-up end, as it passes from
the side opposite to that at which it was first carried, and tie the
two ends together. By this means, the fillet is secured across the
thighs, so that traction may be made upon them, and which must
always be done during a pain, acting in concert with uterine action,
or the bearing-down efforts of the patient. It is very difficult to
adjust the fillet, and, probably its use may be dispensed with alto-
gether. A finger, or the blunt hook, passed between the hips and

THE FILLET — VECTIS — TRACTOR.

551

abdomen, may, with a prudent force, perform all that can be
expected from the ribbon.

It is used, also, to secure the presenting hand in a shoulder pre-
sentation, when turning is attempted, and thus prevent it from
rising and embarrassing the delivery of the head. It should be
applied to the wrist.

The VECTIS, LEVER, or TRACTOR, is an instrument some-
what resembling one blade of the obstetric forceps. It consists of
a steel blade fitted into a roughened handle of hard wood, the
whole instrument being twelve or thirteen inches in length. The
extremity of the blade is expanded like a forceps-blade — is fur-
nished with a fenestra — and one side is so curved as to adapt it to
the convexity of the head of the child. Sometimes it is made
with a hinge for the purpose of carrying in the pocket, and again,
it is made without a hinge, but having the handle to screw on the
blade ; both of these latter forms are objectionable. It is not
necessary to enter into a minute description of the instrument,
from the fact that very few obstetricians of the present day make
use of it; in former times, however, it was much in vogue. {Fig. 62.)

The vectis has been re-
commended for the purpose
of correcting mal-positions
of the head, or of aiding its
movements, whether at the
brim, or in the pelvic cav-
ity; it ha3 also been ad-
vised as a tractor to aid in
the delivery of the head.
The rules for its introduc-
tion are somewhat similar
to those for the forceps.
The instrument should not Vectis< Bf'rNT IIooK> AND Crotchet-
be applied unless the os uteri is dilated and yielding, as also the
soft parts, and labor-pains must likewise be present, or its employ-
ment would be attended with no success. Instead of being secretly
used, as has been frequently the case, the patient and her friends
should be acquainted with the necessity for interference, the same
as in the use of the forceps, and which must never be attempted
unless positively demanded. Then having emptied the bladder,
and rectum also if necessary, place the female on her left side, or

Fig. 62.

Fig. 63.

Fig. 64.

552

AMERICAN ECLECTIC OBSTETRICS.

on her back, as the practitioner prefers — though in the latter posi-
tion, it will be necessary to bring the hips over the edge of the
bed, the same as when the forceps are employed. The operator
will now pass three or four fingers of his left hand, as high up as
possible within the vagina, over the head of the child, to serve as
a director for the vectis — which, having been properly warmed
and oiled, is to be carefully and slowly passed over the convexity
of the fetal head, until the point is reached to which the force is
to be applied. Then withdraw the hand to about the middle of
the instrument, forming a fulcrum with it at that point; the lever
is then of the first kind — the right hand acting on the handle by
pressing it in a direction opposite to the one which it is desired the
head should take. Sometimes, it is formed into a lever of the
third kind, the right hand serving as the fulcrum or point of sup-
port, while the left, at the middle of the lever, gives to it the
necessary movements.

It is frequently the case that the vectis will have to be placed on
several parts of the head in succession, in order to reduce its mal-
position and aid in its descent, and this may be accomplished by
carrying the instrument gently over the circumference of the head,
from point to point, without withdrawing it; and should any diffi-
culty be present interfering with its application, no force must be
employed to overcome it — if it can not be passed without rude
measures withdraw the vectis, and reintroduce it.' It may also be
necessary to use it alternately as a lever, and as a tractor. When
used as a tractor, both hands are to be employed in making firm,
but not violent traction in the direction of the axes of the pelvis,
according to the location of the head, and the efforts should be
made only during the presence of a pain, ceasing during an inter-
val, and slightly raising or loosening the instrument from the
cranium. The least force sufficient for the purpose is the best.
When the head is at the brim, the vectis must be applied over the
occiput; when at the inferior strait, it must be introduced over the
sides. The necessary changes may be effected by only three or
four efforts, sometimes thirty or forty will be required.

At the present day, those who advise the vectis, limit its appli
cation to cases — where the head can not execute its motion of
rotation in the pelvic cavity; in face presentations — applying it
early in labor over the occiput, making traction, while at the same
time the chin is to be pushed up by the hand, for the purpose of
bringing down the vertex; in presentations of the side of the

THE VECTIS — TRACTOR.

553

head — and, likewise, in instances where the head does not advance,
the pains being strong, and where there is only room sufficient for
one blade to act. However, in nearly all these cases, the forceps,
or a manual operation, will usually be found sufficient, and, should
the vectis be required, one of the forcep blades will be found fully
adequate to effect all that can be accomplished by it. I should
hesitate a long time before attempting to use this instrument on
the head, above the superior strait.

In the hands of the unskillful or imprudent operator, the vectis
may occasion serious results; thus, if it be introduced while the os
uteri is not dilatable, nor sufficiently dilated, it will give rise to
contusions, and laceration of the parts, and death to the mother
If it be rudely or carelessly introduced, the vagina or the uterus
may be ruptured. If the traction be not made in the direction of
the axes of the pelvis, as the situation of the head may require,
Dot only will the female be seriously injured, but the operation
will prove of no avail. If a portion of the uterus be engaged in
the cavity of the blade, between it and the fetal head, a fatal
injury may be the result. If the traction be made regardless of
the pains, not only will the operation prove useless, but the female
will be exposed to much danger. If the instrument be pressed
upon the soft parts of the mother, they must suffer more or less
from contusion. If too much force is applied as the head glides
over the perineum, or if this be not supported at the time, a very
serious rupture may be the consequence. Too much pressure with
the point of the instrument upon the child, may occasion a trouble-
some wound.

The Blunt Hook {Fig. 63) consists of a round rod of metal f
curved at one extremity, and having the other fastened into a
roughened handle of hard wood. Hodge's forceps (Fig. 66) are so
arranged that either blade may be employed as a blunt hook ; it
may likewise be obtained in one rod without any handle, the
extremity opposite to the blunt hook being formed into a crotchet.
It is used in presentations of the breech, when delay in the labor
renders it necessary to make traction, and the finger can not be
introduced into the groin, or when the finger can not exert a suffi-
cient degree of traction : it may also be used in those cases where
it becomes necessary to pull down the feet, but which it is imposj
sible to effect by the fingers. It is also occasionally employed in
those cases where, the head having been delivered, the thorax,
36

554

AMERICAN ECLECTIC OBSTETRICS.

from its size, prevents any further advance of the labor ; in these
instances, it is passed into the axilla of the shoulder nearest the
sacrum, to disengage this first. It has also been recommended as
a substitute for the crotchet, when the cranial bones are so loose
as to render it almost impossible to obtain a purchase upon them
by the crotchet: the blunt hook may in these cases be passed
behind an orbit, or into the foramen magnum.

This instrument is to be applied in a manner similar to that
recommended for one blade of the forceps: it should be passed
with its point directed toward the palmar surface of the hand by
which it is guided, and when it has reached the point on which
we design to have it act, give to it a rotatory motion in the direc-
tion of its axis, and thus cause its free extremity to pass into the
axilla or fold of the groin, being careful, in the latter instance, not
to injure the genital organs of the child. After the blunt hook is
applied, always examine and ascertain that it has been properly
adjusted, and is in a position to effect no injury to either the
mother or child.

"When the groin can not be hooked by passing the instrument
in front of the anterior hip, this may be effected by introducing it
between the thighs. An improper use of the blunt hook may give
rise to serious difficulties.

A Placental Forceps has been devised which is extremely simple
and of undoubted utility: they differ considerably from all others
heretofore made, and are pronounced by those who have employed
them to be superior to any others at present in use. They are
made of a single piece or band of steel, bent in the center so as to
form a bow, very much resembling the old-fashioned sugartongs.
From this curve or bow, which serves as a spring for dilatation,
the two arms extend — the whole instrument being about nine
inches in length. The metal, at the curved part, is about three-
quarters of an inch in breadth, perfectly flat, and the curve forms
about three-fourths of the circumference of a circle whose diame-
ter is one inch. The arms, between the bow and the blades, are
made slightly convex on their external surface, in order to render
them firmer, and capable of being more readily introduced within
the uterus. The blades are somewhat broader than the arms,
being about three-quarters of an^ inch broad, ovoid, with the base
forward, slightly convex, and with an ovoid fenestra to allow a
portion of the soft structure of the placenta to pass through and

PLACENTAL FORCEPS.

555

Fig. 65.

Placental Forceps.

thus obtain a firmer hold of it, as well as to present a broader sur-
face to the tender tissue, that it may be less liable to tear or rupture.

The blades, like the arms, are slightly convex externally, con-
cave internally, and
when closed togeth-
er, they present a
flattened amygda-
loid shape, about
three-fourths ot an
inch broad by one-
third of an inch in
thickness. "When
they are closed, the
arms are parallel and
near each other, but
not quite in contact.
The arms are some-
what bent on one of
their edges or margins, so as to correspond with the axis of the
pelvic cavity ; or they may remain straight, according to the fancy
of the purchaser.

The mode of application is, to introduce the index finger of the
left hand into the vagina, with the point of it resting just within the
os uteri ; then, with the blades closed, pass the forceps along the
palm of the hand and the palmar surface of the finger, within the
cervix uteri, and when it has entered an inch or two, allow the
blades to open gradually, and produce as-much dilatation of the os
as may be necessary to admit the ready exit of the placenta. When
this is effected, the forceps are to be gently carried forward with the
blades still open, so that they will pass between the placenta and the
uterine parietes, until they embrace the body of the cake, when they
must be closed and the after-birth be carefully removed. The
advantages possessed by these forceps are : they have no joint to
pinch the vulva, or vaginal walls, or into which the capilli of the
parts may be caught. The blades and arms are perfectly smooth
on both surfaces, and their axis accords with the axis of the pelvic
cavity, which is not the case with any other instrument used for this
purpose. As soon as the instrument has passed within the cavity
of the uterus, its arms open and produce dilatation, so that there
need be no traction made on the organ. The blades are sure to
pass between the placenta and the uterine walls ; and the fenestra

556

AMERICAN ECLECTIC OBSTETRICS.

allows a broad, firm hold on the cake, without the danger of tear-
ing it, which is apt to follow the use of a narrow, rough blade.
{Fig. 65.)

CHAPTER XLII.

THE FORCEPS. — DAVIS* FORCEPS — HODGE's FORCEPS — CASES IN WHICH TO BE USED —
CASES IN WHICH NOT TO BE USED — PERIOD FOR USING THEM.

Formerly, when there was any delay in the advance of the pre-
senting part of the child, from whatever cause, it was the custom to
insert a hook into the eye or some other part of the child's head,
and then apply extracting force ; consequently, but few children
were saved, and those who did live subsequently, were more or less
disfigured or mutilated. Such an operation must have been repug-
nant to every feeling and conscientious man, causing him to post-
pone its performance as long as possible, and which delay would
necessarily add to the hazards of the mother.

But the invention of the forceps has relieved the obstetrician in a
great measure of these unpleasant operations, while at the same
time it has been, and still continues the means of saving the lives of
numerous children, as well as mothers. The forceps were invented
in the sixteenth century, prior to 1647, by Dr. Paul Chamberlen,
who, together with his sons, kept it secret until some time in the
early part of the seventeenth century, when it became gradually
known to the profession. However, it had been employed by
Solinger in Germany, and Palfyn in France, for some time before it
became generally known what the instrument was, or who was its
inventor. Since its introduction the original instrument has under-
gone various modifications, some of which are less objectionable
than others, or, perhaps, are superior only in certain cases. It is
unnecessary to enter into a detailed history of the invention and
introduction of the intsrument, or to describe the many changes
through which it has passed; for such information, there are vari-
ous works to be readily obtained, which contain all the particulars,
and which those who are curious in this matter may consult. The
limits of this work will not permit more than a close adherence to
the practical and useful.

The obstetrical forceps is composed of two arms or branches,
each of which has three distinguishing parts : 1st, the cochlea,

THE OBSTETRICAL FORCEPS.

557

blade, jaw, or clamp, winch is shaped somewhat like the bowl of a
spoon, and the concavity of which is intended to be applied on one
side of the child's head; 2d, the junctura, joint, lock, or hinge, at
which ooint the two blades articulate with each other; and 3d, the
manubrium, or handle— which should be of sufficient length to
enable the accoucheur to operate with facility. The blade of each
branch has an opening or fenestra, which lessens its weight mate-
rially, beside having the advantage of allowing the parietal pro-
tuberance to pass out beyond them, when applied over the sides of
the head, and thus lessening the diameter which would be pre-
sented, were the blades solid; each blade is curved in the direction
of its longitudinal axis, as well as in that of its transverse, which
enables the instrument to be more readily introduced and acted
upon in the direction of the pelvic axis. The joint in each blade
varies, one being furnished with a pivot and the other with a notch
or mortise; when the two are properly united, the blades are firmly
locked. To distinguish the blades from each other, the one with
the pivot is termed the male blade, and that with the mortise, the
female blade. The handles are similar in each, having a curvature
externally, which not only admits of their being firmly grasped
without slipping, but also serves to fulfill all the purposes of a
blunt hook.

There are two descriptions of forceps in general use, the short
and the long; the former were more in vogue some years ago, but
since the excellent improvements made in the long forceps by Prof.
Hodge, it is coming more into favor — because, while it possesses
all the benefits of the short forceps, it has an advantage in its
applicability to operations at the brim, when these are required.
The short forceps are only useful when the head is at or near the
inferior strait.

Nearly every obstetrician has some favorite model of this instru-
ment; but among the short forceps, I believe those of Prof. Davis,
of Loudon, are more generally preferred by the profession of this
country. Prof. Meigs, who has adopted them, gives the following
description : "It weighs ten ounces and three-quarters, and is in
length twelve inches; its lock is the English lock, composed of a
notch in the upper surface of the left and in the lower surface of
the right hand branch. When the handles are closed, the ends of
the clamps are seven-tenths of an inch apart, while the fenesters,
at their widest part, are two and three-quarter inches asunder.
The broadest part of the fenester is equal to two inches, while its

558

AMERICAN ECLECTIC OBSTETRICS.

whole length is five inches. From the extremities of the handles
to the lock or point where the branches cross, is four and a quarter
inches. After the branches are crossed, they do not divaricate, but
proceed in parallel lines one inch and a quarter; hence, if a fetal
head be ever so considerably elongated by the pressure of the parts,
the clamps are sufficiently capacious to contain it, being seven
inches long. In this instrument, such are the width and length
of the fenestrse, that a large part of the parietal protuberances jut
out through or beyond them when they are fixed on the head."
* * * "Its interior face is perfectly adapted to the rotundity
of those parts of the head which it touches ; while the fenestrse
are so vast as to permit considerable portions of the parietal pro-
tuberances to project as segments of curves outside and beyond the
fenestral openings. It would be true to say, that the instrument,
when accurately adjusted upon the sides of the cranium, scarcely
touches the maternal tissues within the pelvis. The exterior curves
are also arranged so accurately that the tissues of the mother can
never touch the edges of them ; so that they can not be cut by them,
the surfaces of contact being everywhere broad and gently rounded*
The admirable form of the old-curve or head-curve, enables the
instrument to touch very large portions of the cranial surfaces,
pressing them equally, and not unequally; so much so, indeed,
that, when the instrument is accurately applied, it would be a very
difficult matter to do with it the least injury to the fetus, since it
can scarcely slide."

But, however useful the above forceps may be, it is a matter of
considerable moment to so simplify all our instruments, that one
only of them may be adopted to the accomplishment of several
purposes; and this is more especially necessary in obstetrics, in
which it frequently occurs that delay, even of a short interval, is
attended with serious results. On this account Hodge's improved
long forceps are more usually preferred than others, not only be-
cause of their lightness and their correct form and adaptation to
the purposes for which they are intended, but likewise because
they combine the utility of the short forceps, the long forceps, the
vectis, and the blunt hook. It is the one which I prefer, and which
I recommend to the classes attending the Institution in which I
occupy the obstetrical chair. This instrument is a modification of
the long French forceps, and is described 4)y Prof. Hodge himself,
as follows:

" The great object of the forceps is to extract the head of the

hodge's forceps.

559

fetus from the mother's organs, in suitable cases, without injury to
the mother or child. It is notorious that injuries to one or both
parties frequently result, excitiDg a too well-founded dread of this
instrument in the minds of females, and even of physicians. Many
causes contribute to this unfortunate result. No doubt much
depends on the size, weight, and especially on the form of the
instrument employed, a fact confirmed by the almost innumerable
varieties which have been suggested. The instrument, as hereto-
fore used, is evidently imperfect; and the one now suggested, is
presented under the impression that, while it maintains all the
excellencies of the former varieties, the injurious influences are
partly, if not wholly, avoided. It is a modification of the long
French forceps, but may be well termed an eclectic forceps, as com-
bining, as much as possible, the peculiar excellencies of the English,
German, and French varieties.

" The advantages of the French or long forceps are, I think,
many and decided, as, 1st, by them, any operation pertaining to
this instrument, can be performed. There is no necessity to vary
the form, structure, or size, of the instrument, whatever may be
the presentation of the head, its position, or its location. 2d. By
them, sufficient power can be applied in cases of necessity, which
can not be done by the short forceps. Their leverage is greater.
3d. The narrowness of the blades, which, without detracting from
the utility of the instrument, will allow of their application to the
sides of the head, even in oblique and transverse positions. Many
of the modern English forceps are too broad to allow the proper
manipulation of the instrument in the cavity of the pelvis. They
can not be introduced through the vulva without pain, especially
in first labors. The French forceps can very generally be applied
without pain.

" 4th. It may be added as another advantage, that as habit in
the use of an instrument is all-important, the practitioner willj
sooner become accustomed to a forceps which he can employ on a]
occasions, than when he is obliged to vary it continually; especially
when it is remembered that among the strong and well-formed
females of America, cases for the forceps are not very numerous in
the circle of any practitioner.

" The disadvantages, which experience has taught me arise from
the French forceps, are:

" 1st. Its unnecessary weight.

" 2d. The pelvic curve, in the variety most in use in this country,

/

560

AMERICAN ECLECTIC OBSTETRICS.

is not sufficiently great. Hence when the head is high in the pel-
vis, the perineum will be too much pressed upon, or else the blades
will be applied in the direction of the occipitofrontal or longitudi-
nal diameter, instead of the occipito-mental or oblique diameter.

" 3d. The divergence of the blades commencing at the joint must
necessarily distend the vulva (especially its posterior margin) pre-
maturely, and when the head is high up, gives pain and endangers
the laceration of the perineum.

" 4th. The small size and kite-like shape of the fenestra prevents
any portion of the cranium, even of the parietal protuberances pro-
jecting into their openings : hence the hold on the head is less
firm, and space is occupied by the blades, the thickness of which
is added to the transverse diameter of the head.

" 5th. The flatness of the internal or cephalic surfaces of the
blades, so that the margin of the fenestra, often measuring three-
eighths of an inch, is much thicker than the external edge of the
blade, increases the space occupied by the instrument. Hence in
cases of difficulty, where compression is employed, contusion or
even wounding of the scalp results.

" 6th. The mode of junction of the French forceps is decidedly
inconvenient when compared with the English, and especially with
the German mode.

"These disadvantages I have endeavored to obviate without
diminishing or circumscribing the utility of this most valuable
instrument, to which the profession and the public are so much
indebted. My experience encourages the hope, that the attempt
has been in a very great degree successful, so that even in inex-
perienced hands, the dangers of the forceps have been materially
lessened.

"1. The weight of the instrument has been diminished from
twenty ounces, avoirdupois, to seventeen ounces.

" 2. The pelvic curve has been slightly increased, so that the
perineum may not be dangerously pressed upon when the blades
are in the axis of the superior strait. To counteract any loss of
power which may ensue from the increased curvature, there is an
angular bend in the handles, in an opposite direction, that the
direct line of traction may be preserved, a suggestion of our skill-
ful and experienced instrument maker, Mr. Rorer.

"3. The shanks or commencement of the blades are nearly par-
allel, diverging no more than is absolutely necessary, until they

hodge's fokceps. 561

approximate the head of the child, when a more rapid curvature,
than in the Levret forceps, occurs.

"4. The proper blades of the instrument, from the shanks to the
extremities are nearly of the same breadth throughout, being equal
to that of the extremity of the French forceps.

"5. The advantages are a more secure hold of the head, and
especially allowing larger fenestra, so that the parietal protuber-
ances may project into the openings, and no space occupied by the
blades, when properly applied.

"6. The cephalic surface of the blade is concave, so as to be
adapted to the convexity of the head, as suggested by Dr. Davis
in his improved forceps, hence no edges touch the scalp, and
there is no wounding of the tissues, even when great compression
is made.

" 7. The very ingenious and scientific mode of locking the blades,
as in the German or Siebold's forceps, by means of a conical pivot,
and the corresponding oblique conical opening for its reception, is
adopted, by which all the facilities of the English junction are
enjoyed, and the security and firmness of the French joint are
maintained.

" The eclectic forceps weighs one pound and one ounce, being
nine ounces lighter than the French forceps, as usually manufac-
tured by Rorer, of this city, and eleven ounces lighter than a
specimen of Dubois forceps in my possession, made in Paris.

"The whole length of the instrument {Fig. 66) in a direct line
from b to c is 16 inches; from the joint a to the extremity 6, the
length of the handles, is 6*8; from a to d, length of parallel
shanks, is 3-5 ; from d to c, the proper blades in a direct line, is 6
inches; from c c, the extremities, to e f, the greatest breadth, 3*7
inches.

"The separation between the points c c, when the handles are in
contact, is *5 of an inch; from e to /, the greatest breadth when
the handles touch, is 2-5; when the separation at e f is 3*5, the
points c c are separated to two inches; the breadth of the blade is
1-8, slightly tapering to 1*7 near c c, the extremities. The breadth
of the fenestra is 1*1 ; the thickness of the blade is -2 of an inch.
The perpendicular elevation of the points c c, when the instrument
is on a horizontal surface, is 3*4 inches, which indicates the degree
of curvature of the blades.

"The elevation of the handles near the point, above the same

562 AMERICAN ECLECTIC OBSTETRICS.

horizontal line, is 1*3 (including the thickness of the blades),
which indicates the extent of the angular bend in the handles."

Fitt 66.

Hodge's Forceps.

It is sometimes the case that the head is delayed in its descent
in consequence of its bi-parietal being slightly larger than the
antero-posterior diameter of the superior or inferior strait ; in such
instances, the instrument of Prof. Hodge may be applied along
the sides of the head, and sufficient compression be made upon
this diameter to insure its passage through the brim, and into the
pelvic cavity, or through the outlet. Too much compression,
however, will destroy the child, and this should always be kept in
mind when operating.

From experiments instituted by Baudelocque, upon several still-
born children, as to the amount of compression which the fetal
head will safely bear, he found that the degree of reduction which
the diameters may harmlessly undergo, is very inconsiderable, not
exceeding four and a half, or five lines; that the extent of the reduc-
tion depends much upon the more or less perfect ossification of the
cranial bones, and the ratio of closure of the sutures and fonta-
nelles, and that it can not be properly estimated from the amount

USE OF FOKCEPS.

563

of force employed in approximating the handles, nor from the dis-
tance remaining between them when thus approximated in deliver-
ing the head.

Prof. Meigs most emphatically pronounces the forceps to be
the child's instrument, and not the mother's — that it is by no means to
be viewed as a compressive instrument, but always as an extractor; a
declaration which should never be forgotten by the obstetric
operator.

However, it maybe proper to state, that there are many accouch-
eurs who, though recognizing the correctness of Prof. Meig's remarks
on this point, as a general principle, yet consider that there may be
some exceptions, as in moderately contracted pelves, in which a
gradual compression of the head may effect delivery, without evil
results to either the child or its mother. Among them I may name
Dr. Rigby, who says: " The slow and gradual pressure of the for-
ceps thus exerted (by tying the handles together and tightening
them after every successive effort), upon the head of a living fetus,
will have a very different result to that of the experiments of Bau-
delocque and others, in attempting to compress the head of a dead
fetus, by the application of a sudden and powerful force." So that
from these remarks, it may be well to consider the use of the for-
ceps as a compressor, above the brim, either when its diameters are
slightly diminished, or the bi-parietal of the head somewhat aug-
mented, as mere exceptions to the general rule, that the forceps are not
intended for compression. And when compression is made, it should
never be in the direction of the occipitofrontal diameter, but
always in that of the bi-parietal, as being less likety to injure the
child. Judicious management will frequently render a resort to the
perforator unnecessary.

In some countries the forceps are employed much more frequently
than in others ; thus, according to Churchill, in 52,268 cases of labor
occurring in-British praqjice, the forceps were applied in 144 cases,
or about 1 in 362f . In 44,736 labors in French practice, they were
used in 277 cases, or about 1 in 162 ; and in 261,224 labors in Ger-
man practice, they were resorted to in 1,702 cases, or about 1 in 153J.
The whole amounting to 358,228 cases of labor, in which the instru-
ment was applied 2,123 times, or about 1 in 168|. The results to
the mother in British practice, was 1 death in 20| cases ; to the
child 1 in 4|. In French and German practice, 1 mother was
lost in 13J, and about 1 child in 5. As the result to the mother has
not been named in many instances, nor the peculiarities of each

564

AMERICAN ECLECTIC OBSTETRICS.

case given, these statistics can be considered as only approximative.
In our own country, the statistics have been too meager and lim-
ited to enable us to form any idea of the comparative frequency ot
forceps labors, or their results.

The cases in which a resort to the forceps has been advised, are
the following — recollecting, however, that the short forceps are
never to be used when the head has not passed the superior strait :

1. To effect delivery in cases where the uterine contractions are
weak and inefficient, and can not be aroused by the ordinary means.
Nor should they ever be applied, unless we are fully satisfied that
the natural powers are inadequate to effect the delivery without
hazard to the mother or child. Thus, the head may be in the supe-
rior strait, not impacted, but making no advance in consequence ot
the inefficiency of the pains ; here the long forceps have been
advised to assist in accomplishing the descent. Or, the head may
present at the brim, in a mal-position, which, not being corrected .
by the pains, as well as being incapable of reduction by the hand,
may be rectified by the long forceps, provided the os uteri be in a
proper condition.

In the use of the long forceps, I would remark here, that when
employed at the superior strait, the blades are to be introduced in
the transverse diameter of this strait, so that a blade will be within
each ilium ; while both the long and short forceps, are to be intro-
duced over the sides of the child's head when it has entered the
pelvic cavity, a blade being over each ear — and which rules must be
borne in mind when the long forceps are employed as a substitute
for the short ones.

2. To hasten delivery when dangerous symptoms to the mother
are present, whether from too prolonged labor, hemorrhage, convul-
sions, exhaustion, rupture of the uterus when the head is within
reach, or from resistance of the muscles of the perineum.

3. To save the child's life in some face presentations, and in the
occipito-posterior positions when the forehead is behind the pubic
symphysis. This, however, is not necessary in all instances of the
above character, as delivery frequently terminates by the natural
efforts, though more slowly, and with a greater amount of suffering
than in ordinary cases.

4. To preserve the child in prolapsus of the cord, when the pul-
sations grow weak.

5. When there is a detention of the head within the pelvic cavity,

USE OF FORCEPS.

565

heretofore referred to when speaking of the compressive action of
the instrument.

6. When an extremity descends with the head, and can not be
returned, the augmentation of the diameter within the pelvis, may-
require a greater degree of expulsive force than can be given by
the natural powers.

7. In breech labors, when there is a delay in the advance of the
head, the body and extremities having been delivered, the child may
die, unless it be removed by the forceps.

The forceps are never to be employed when the os uteri is rigid
and undilatable, or relaxed but not sufficiently dilated ; when the
soft parts are inflamed and swollen ; when the diameters of the
pelvic cavity are diminished by the presence of tumors ; in deform-
ities of the pelvis; when the child is dead; and when the fetal
head is hydrocephalic, or firmly ossified. Neither is it to be applied
to the breech. And unless there exists some urgent reasons for
their use, as hemorrhage, large head, small pelvis, convulsions, etc.,
they are never to be employed except the pains are inefficient.
Indeed, the instrument should always be considered the "child's
instrument," and a substitute for absent or inefficient expulsive
force of the uterus; and, under no circumstances whatever, is it
justifiable to employ them to save trouble, or in any other way
accommodate the convenience of the practitioner.

"When the uterus acts energetically, the pulse not being over
one hundred beats in a minute, the countenance natural, the spirits
good, the tongue and mouth moist and clean, the abdomen and
soft parts free from pain on being pressed or touched, and the
head makes the slightest advance, no interference is required, not-
withstanding the labor may have continued over twenty-four
hours.

If attempts be made to introduce the forceps before the os uteri
and soft parts are in a favorable condition, rupture of the uterus,
or laceration of the perineum and vagina may be the consequence,
and which, when occurring, always proves more or less hazardous
to the mother. Nor is it proper to carry the forceps within the
os uteri, until it has so far risen above the parietal protuberance
that it can not be felt.

When the soft parts are swollen and inflamed, a condition which
will seldom occur in the hands of a careful accoucheur, it will be
inexpedient to use the forceps, because of the disposition to slough-
ing of the parts under such circumstances, and, therefore, the per-

566

AMERICAN ECLECTIC OBSTETRICS.

forator will be the safer instrument for the mother. The same
course will be pursued in diminished pelvic diameters from tumors,
deformities, or other causes. In these cases the child must be sac-
rificed for the safety of the mother — this is a fundamental principle
of obstetrics. Generally, in instances where the perforator will be
required, the pressure will destroy the child, before the symptoms
become so threatening as to induce a skillful obstetrician to operate.

When the child is known to be dead, which may generally be
determined by the stethoscope, the perforator is advised in pref-
erence to the forceps ; and this is likewise recommended in hydro-
cephalic or ossified heads, to be used, even before the child's death,
if the safety of the mother requires it.

As the instrument is intended for the head only, it could not be
applied to the breech with any degree of safety or success
would be very apt to tear or mangle the soft parts of the breech
and trunk upon which it might be exercised. But it may be fre-
quently used with advantage to extract the head, after the body of
the child has been expelled, when any difficulty or delay occurs in
its delivery.

In impacted or locked head, the perforator will generally be
required, on account of the impossibility of moving the head with
the forceps ; this condition of the head is usually connected with a
small pelvis,, or a large, and perhaps ossified head. But in cases
where there is a mere arrest of descent, from a close fitting of the
circumferences of the head to those of the pelvis, the forceps may be
used. (See note, page 381.)

In all cases where the head is considerably larger than the pelvis,
the forceps, as well as a resort to turning are improper ; and either
the perforator or the Cesarean operation will be required. Yet, as
our means of accurately determining the size either of the head or
of the pelvis, are not always absolute, it is never improper to attempt
the delivery by a careful and gentle employment of the forceps. It
will frequently happen that when the antero-posterior diameter of
the brim has not reached three inches, the forceps may be success-
fully used.

The PERIOD FOR OPERATING, will depend entirely upon
the circumstances attending each individual case. Previous to the
rupturing of the membranes, the employment of the forceps will
be unnecessary; but after their rupture, in ordinary cases, we are *
to be guided more by the constitutional symptoms than by a mere
lapse of time. There is one exception to the statement just made,

USE OF FORCEPS.

567

and that is when the difficulty is at the superior strait, and the
head can not descend through it, in this case, as too great a delay-
may give rise to serious symptoms, the second stage may be con-
sidered to have commenced as soon as the os uteri is fully dilatable.
The general rule upon which to act, is, not to interfere until the
second stage of labor has continued for twenty-four hours without
delivery having been accomplished. But, although as a general
rule, this is entitled to much attention, it frequently occurs that
symptoms present themselves before the twenty-four hours have
expired which demand interference; and, again, many females
will sustain a prolonged and painful labor, with more fortitude,
and less prostration of the system, or other unfavorable symptoms,
than others. We must, therefore, be governed 'principally by the
symptoms, and partly by the lapse of time, being careful not to
delay too long, or until the parts become dry and inflamed, and the
labia and perineum become infiltrated with serum, for then, lac-
eration and sloughing will almost inevitably ensue. If the head
remains arrested for four hours, we are justified in operating even
though no unfavorable symptoms exist, because by so doing we
preserve the integrity of the soft structures.

In the selection of the proper period for operating with the for-
ceps, in connection with what has already been stated, an attention
to certain circumstances, will materially assist us. Thus — if the
health of the female has been impaired, or if she has previously
suffered from a long-continued sickness, the powers of the system
will be less likely to sustain her under a lingering labor, or to
terminate the delivery, than when she has been in the possession of
good health ; though we often meet with females laboring under
consumption, dropsy, etc., whose labors are as vigorous and natural
as those of the most healthy and robust. If the female has previ-
ously given birth to children, there is a greater reason to suppose
that the present one may also be born without aid, unless there
exist a mal-position or abnormality of the head.

If twenty-four hours have elapsed since the commencement of
the second stage of labor, the forceps will very probably be required,
but we should not be too hasty, even then, in their application,
being governed, in a great measure, by the symptoms present. Yet
we must remember that if the head remains stationary, pressing
upon the soft parts for, four hours, their structure becomes much
endangered. But " if the4head advances ever so slowly, the patient's
pulse continuing good, the abdomen free from pain on pressure, and

568

AMERICAN ECLECTIC OBSTETRICS.

no obstruction to the removal of urine," the strength and spirits of
the patient being also good, interference, as a general rule, is not
required, unless the child be dead. The mortality to the mother
and child, in cases where this rule has been applied, is less than
among those where the forceps have been resorted to, and, it must
also be borne in mind, that the death of the child alone does not
justify any interference, unless there be sufficient cause aside from
this fact.

The condition of the patient's strength, and her capacity of endur-
ance must also be taken into consideration; and we must be care-
ful not to be misled as to the exhaustion of the female. The uterus
may be acting energetically, and the woman be walking about the
room, and yet she will complain of being exhausted ; the practi-
tioner must be guided by other symptoms than merely such
expressions. When exhaustion is present, the pulse will be very
quick, over one hundred beats in a minute; below this there is
seldom any danger. The pains, also, gradually become weak, with
lengthened intervals, and finally cease ; and accompanying this con-
dition there will be a greater or less discharge from the vagina, of a
faint, unpleasant, but not putrid odor, and of an olive color, and
which is, probably, the secretion from the lining uterine membrane,
changed in consequence of the long-continued and powerful exer-
tions of the organ ; this may be considered one of the first mani-
festations of exhaustion. The countenance of the patient assumes
an anxious appearance, the cheeks become pale, sallow, or spotted,
the eyes sunken and dull, and the tongue will be dry and loaded,
either with a brown sordes, or, if fever is preseut, with a white fur.
The respiration is also hurried, and other unfavorable symptoms
may appear. Vomiting of a dark fluid, having the appearance of
coffee-grounds is most generally present, when exhaustion has
advanced ; and when a long period has been allowed to elapse, a
shivering coldness of the extremities with cold, clammy perspira-
tion on various parts of the body, and delirium come on, indicative
of great local injury and extreme danger.

The condition of the abdomen, and of the soft parts, will also
indicate the period for operating. Thus, if there is tenderness of
the abdomen on pressure, inflammation is to be dreaded; and deliv-
ery will be the safest course to pursue. If the soft parts, instead
of being cool, soft, and moist, become dry, hot, swollen, and pain-
ful, so that the least touch can scarcely be allowed, it has been
advised by some writers to deliver by forceps; but from the ten-

RULES FOR APPLYING THE FORCEPS.

569

dency to sloughing in such cases, I do not deem it the best practice.
Still, an attempt to subdue the tenderness and inflammation by the
application of fomentations may be undertaken in such cases;
always, however, recollecting that the danger increases in pro-
portion as the pressure is continued. To wait, however, for the
appearance of vomiting of dark fluid, of cold shiverings or sweats,
hurried breathing, delirium, or swelling and inflammation of the
soft parts, would be extremely injudicious.

In all these protracted cases of labor, great vigilance is required
that we do not delay the operation so long as to endanger the life
of the mother; and if there is a chance for saving the child's life
without any injury to the mother, the delivery may be undertaken
even before those symptoms appear which indicate a failure of the
powers of the system. There is always a greater possibility of
injury from too long a delay, than from interfering a little too soon.

Occasionally circumstances will exist which demand the use of
the forceps for delivery before the rupture of the membranes; in
such cases, if the os uteri is in a favorable condition (and positively
not without), the membranes may be artificially ruptured and the
instrument applied. Such instances are, fortunately, very rare.

The principal dangers to which the mother is exposed when the
forceps are used, are laceration of the vagina, or of the perineum,
or of both; laceration of the cervix; and contusion of the soft
parts. The child may have its head too much compressed; its
scalp, or ear, may be bruised or torn; and the pressure may induce
paralysis of the facial nerve.

CHAPTER XLIII.

RULES FOB APPLYING THE FORCEPS MODE OF APPLYING THE FORCEPS IN THE VARIOUS

POSITIONS OF THB HEAD.

Before stating the manner of applying the forceps, I will briefly
recapitulate a few of the general principles referred to in the pre-
vious chapter, and which should be constantly kept in view by the
accoucheur.

1. When the powers of nature are sufficient to effect the deliv-
ery, interference is not required, unless circumstances occur which
threaten the life of the mother.
37

570

AMERICAN ECLECTIC OBSTETRICS.

2. The forceps, acting as a substitute for the natural efforts, are
to be employed as an extractor, and not as a compressor.

3. They are never, under any conditions whatever, to be used,
unless the os uteri is sufficiently dilated and dilatable.

4. They may be used when a delay in the delivery would endan-
ger the child's life, but never at the expense of injury to the
mother.

5. Under ordinary circumstances, they should not be applied
until the symptoms of exhaustion commence; neither delaying
too long until the mere severe symptoms come on, nor operating
too prematurely.

6. They must not be used when the soft parts are inflamed or
(swollen, on account of the tendency to subsequent sloughing;
neither must they be applied to any part of the child except the
head.

7. The lateral motion or oscillating movement from handle to
handle must not be allowed to take too extensive a range; and
remember, that the higher up the forceps are passed within the
pelvic cavity, the more limited will be the extent of these motions,
and greater attention will be required not to injure the maternal
soft parts.

8. Always avoid hurrying the head through the inferior strait,
and fail not to give support to the perineum as it becomes extended
by the advance of the head.

Previous to the introduction of the forcep-blades, the patient, as
well as her friends, must be made acquainted with the character of
the operation, and the necessity for it; for it is not to be supposed
that any physician would attempt an operation of this kind, with-
out the consent of the patient or her relatives. It may, likewise,
be a judicious measure, in cases where imperative haste is not
required, to show the instruments and explain their method of
operating — remarking that, as the hands can not be applied to the
eides of the head to assist in its delivery, these are employed as
substitutes-: and that, in the hands of a careful operator, they will
not be apt to cause injury to child or mother. Whenever it is
possible to procure the presence of another accoucheur with whom
to consult and share the responsibility, it should be done, and will
be found a very judicious measure.

Consent having been obtained, the bladder must, in every in-
stance, be evacuated, either naturally or by catheter; and if the
rectum has not been recently emptied, or if there be an accumula-

ROLES FOR APPLYING THE FORCEPS. 571

tion of feces, an injection should be administered. But should
the injection fail to clear out the rectum, and the symptoms de-
manding delivery are urgent, the practitioner may proceed to the
application of the forceps, having, however, been careful to empty
the bladder.

The practitioner, having turned up his coat sleeve and shirt
wristband, and also protected his dress from being soiled, by an
apron or something to serve a similar purpose, will have the female
brought to the edge of the bed, lying upon her back, as in the
position for turning, her feet resting on two chairs, separated suffi-
ciently from each other to permit him to sit or stand between
them, and her limbs are to be supported by two assistants (not
necessarily professional friends), who are to sit with their backs
toward each other. The patient's hips should be brought so far
beyond the edge of the bed, that no obstacle will be offered to the
introduction of the forceps, or the free use of them after having
been applied.

In order to prevent the floor from being soiled by the discharges,
some cloths should be placed upon it immediately under the hips
of the woman, and that part of the bed on which the inferior
portion of her body rests, should also have several folds of
blankets or other suitable articles placed there, to protect the bed
from the discharges. The female should never, under any circum-
stances, be exposed: a sheet or blanket, according to the condition
of the weather, should be thrown over her. And in order to facil-
itate the introduction of the blades, lard or some other unctuous
substance should be freely applied to the soft parts.

These preliminary measures having been attended to, and the
operator knowing the exact position of the head, he may sit or stand,
as preferred, and proceed to introduce the blades. These, having
been previously warmed to a temperature equal to that of the
patient, by placing them in warm water, are to be well greased,
and each blade is to be held in its appropriate hand, somewhat
similar to the manner of holding a pen, although rather more
firmly — or it may be held in the manner of a bistoury while mak-
ing an incision. Generally, the male blade, or the one introduced
by the left hand, is applied first, then the other; and the introduc-
tion should invariably be effected during the absence of labor-
pains, ceasing all efforts when these return.

Some writers advise that blade to be introduced first which is
applied along the posterior part of the cavity, and this will proba-

572

AMEKICAN ECLECTIC OBSTETRICS.

bly hold good in a number of cases; but, as a general rule, it will
be found better, in practice, to introduce that blade first which is
the least easily applied, always being careful to so apply them that
they will readily lock.

Having carefully passed in two or three fingers of the hand not
occupied in holding the blade, and insinuated them between the os
uteri and the fetal head, both as a guide for the application of the
blade, and to prevent the os uteri from being included in the grasp
of the forceps, each blade is to be successively and carefully passed
over the sides of the head. If the head is high up, it will then be
necessary to introduce the whole hand within the vagina, for the
purpose of properly guiding the blades; and the direction of the
axes of the pelvis, should not for a moment be lost sight of. Each
blade must be passed inward with a waving motion, but without
any force, and must also be kept in constant contact with the head
during the introduction. Should either blade meet with any
obstacle to its advance, it must not be forcibly thrust forward, but
should be passed beyond the difficulty by careful and adroit man-
agement, withdrawing the blade, if necessary, for a reintroduc-
tion ; should any force be employed to overcome the resistance, the
ear, or a fold of the skin, or the soft parts of the mother, would,
probably, be torn, and which would reflect much discredit on the
skill and attainments of the operator.

As a general rule, the forceps are to be applied wTith their con-
cave surface grasping the sides of the head in the direction of the
occipito-mental diameter; and they are always to be so applied,
that at the termination of the delivery, when the head is emerging
from under the pubic arch, their concave edges will be brought under
and facing this arch. By considering for a moment, whether the
occiput or forehead is to be brought under the pubic arch, the
practitioner can not fail to properly apply the instrument, for the
concave edges of the blades must always be directed to that part
of the head which passes under this arch, as it emerges from the
outlet.

After the first blade has been applied, it may be held by an
assistant until the second one has also been applied, which latter
should be introduced above the male blade, in order that they may
lock readily. If they do not lock easily, and without force, no
rude or violent attempts at twisting or wrenching them round
should be made, but the female blade should be removed and
re-introduced, and it were better to repeat this several times than

RULES FOR APPLYING THE FORCEPS.

573

to attempt an adjustment by force. Occasionally, it may become
necessary to withdraw both blades, and reapply them. When
properly locked, a finger should be passed around the lock to
ascertain that no portion of the soft parts, or of the genital hair,
are fastened within it.

Having effected the locking, and removed any hairs, etc., which
may be found entangled within the lock, screw down the pivot, by
giving it two or three turns, grasp the handles firmly and make
slight compression and traction, to ascertain that the instrument
is firmly applied, and that no part of the vulva, vagina, or os uteri
is included; and which latter circumstances may be known by the
violent pain produced — when a withdrawal and readjustment of
the instrument will be necessary.

The forceps being properly applied, the operator may now pro-
ceed to deliver. Seizing the handles with the right hand, he will
hold them together with a sufficient degree of firmness to prevent
their slipping from the head, and without exerting an undue com-
pression upon it. The left hand must be applied over the lock of
the forceps, with the index finger extended so as to touch the ver-
tex of the child, and thus enable him to ascertain whether the
head advances or not with the motion of the instrument. If it
does not advance, the finger will be found to leave the vertex as
the operation proceeds.

If the handles are held in the left hand, the right should be
applied, as above, to the lock ; and the middle finger of the hand, at
the lock, may be placed in front of it, that is on the part facing the
child's head, to aid in the extraction, should more extractive force
be required. The index finger must not be removed from the head
until it emerges from the vulva; and should it leave the head, the
operator must cease action, lest the blades suddenly slip off, and
perhaps, occasion a serious injury to the parts.

The traction should always be made in the direction of the axis
of that part of the pelvis, at which the head is successively placed,
and must be made only during a pain, ceasing in its absence; or,
should the pains have become entirely suspended, the operation
should be continued only for two or three minutes at a time, request-
ing the female to bear down while acting, if she does not do
so naturally, allowing intervals between each effort, and thus
imitating, as closely as possible, the course pursued by nature.
During the intervals relax the handles, and relieve the head from
pressure.

574

AMERICAN ECLECTIC OBSTETRICS.

In accomplishing traction, the impulse of the force employed,
although guided in the direction of the pelvic axis, successively, is
effected by a lateral motion, from handle to handle, keeping the
instrument at first, as far back to the perineum as possible, in
order to act in the direction of the axis of the pelvic brim (if this
be necessary), and elevating the handles as extension ensues and
the head emerges from under the pubic arch. About two-thirds
lateral force, and one-third extractive force should be given ; and
the nearer the head is situated toward the brim, the more limited
will be the extent of the motion from side to side, while at the
outlet a large sweep may be taken.

Most usually the rotation of the head occurs with its descent,
carrying the forceps along with it as it rotates, without any effort
of the practitioner. But should this motion of rotation not be
effected naturally, it must be accomplished by the operator, not
by violent exertions, nor by twisting the head, but by continuing
the tractions from handle to handle, at the same time slowly and
gradually giving to them the proper direction in which the head
must rotate.

This lateral extractive motion causes the instrument to act as a
double lever, and in effecting the change in the motion from side
to side, the operator must be very careful to retain every fraction
of an inch which the head advances, not allowing the advance
made by one lateral extractive movement to recede when he
carries the handles in an opposite direction. Should the contrac-
tions of the uterus come on powerfully, and the head commence
advancing naturally, after a few motions of the instrument, the
rest of the labor may be left to nature ; but the forceps must not
be removed until the head is delivered, because, if, from an errone-
ous view of the natural efforts, the removal of the blades has
been premature, requiring a subsequent reapplication, it places
the operator in a very discreditable and mortifying position.

As the head passes over the perineum, this must be carefully
supported by an assistant, and the operator should slowly and
carefully deliver the head, requiring the patient to lie still, lest
any sudden movement on her part, might cause a severe laceration
of the perineum. Generally, when the head reaches the outlet,
it will occasion tenesmus and sufficient contraction to terminate
the delivery, without any further efforts at traction, and all
required of the operator will be to gradually carry up the handles
of the instrument in front of the pubis, and thus favor the move-

RULES FOR APPLYING TUB FORCEPS.

575

ment of extension ; improper traction at this time will almost
always cause a rupture of the perineum. But should there he any
difficulty in the advance and extension of the head, a moderate
degree of traction will then become necessary. Remove the for-
ceps after the birth of the head, attend to the remainder of the
delivery, the same as in a natural labor.

Having now given the general rules for the employment of the
forceps, it will be proper to refer to its special applications, in each
position of the head or face ; commencing with those instances in
which the vertex has reached the inferior strait.

LEFT OCCIPITOANTERIOR POSITION.

This position (as well as all others), should be positively, and cor-
rectly ascertained by a vaginal examination ; and if the practitioner
is not satisfied with the signs detected by the finger alone, he
should not hesitate to introduce three or four fingers, or even the
whole hand, extending the fingers over the head, and ascertaining
its true position by feeling its various points.

Having the patient properly situated, he will take the male or
left hand blade of the forceps in his left hand, and using two or
three fingers of his right hand as a guide, he will carefully intro-
duce it along the left side of the child's head and in front of the mater-
nal left sacro-iliac symphysis, carrying it upward until the extremity
of the blade reaches the chin of the child. "When the blade is about
to be introduced at the vulva, in the direction of the axis of the
inferior strait, the handle will lie in an oblique manner over the
right groin of the patient, and as the blade passes within the vagina,
being guided in the direction of the pelvic axis, the handle will be
gradually depressed between the woman's thighs, approaching nearer
and nearer toward the median line. When properly applied, the
handle will be directed toward the left thigh of the mother, the
pivot will look upward and to the left, and the concave edge of the
blade will be directed toward the left acetabulum. Having an
assistant to hold this blade, the operator will take the female or
right hand blade in his right hand, and with the fingers of his left
hand as a guide, he will introduce it, above the male branch and
nearly opposite to it, in front of the right foramen ovale, gradually
conducting it along the side of the head in the occipito-mental
direction. When this blade is about to be introduced, the handle
will lie obliquely in front of the left groin, and as the blade passes
within the vagina, the handle will be gradually depressed between

576

AMERICAN ECLECTIC OBSTETRICS.

the thighs of the patient, approaching by degrees toward the
median line. As soon as this blade has entered to a sufficient dis-
tance, and been properly adjusted on the r,ight side of the head-
both blades being as nearly as possible in the direction of the
occipito -mental diameter, of the child's head— they will lock with-
out any difficulty. When locked, both handles will lie toward the
left thigh of the patient, that of the male blade being uppermost,
and the pivot will be directed upward and to the left.

The head being at the inferior strait, as soon as a pain comes on,
commence the traction in the direction of the axis of this strait; as
the head advances it rotates, the concave edges of the forceps-
blades are brought under the pubic arch, and as the movement
of extension takes place, the handles must be gradually carried
upward in front of the pubic symphysis and abdomen. Accom-
plishing the remainder of the delivery in the usual way.

RIGHT OCCIPITO-ANTERIOR POSITION.

In this position the male blade, which, in all cases, is to be held
in the left hand, must be introduced, along the fingers of the right
hand, within the left side of the vagina, and by means of a spiral
movement, it should be gradually drawn forward so as to apply its
concave surface to the left side of the child's head. The handle
will at first be inclined obliquely over the mother's right groin,
but as the blade advances it will gradually be depressed, and when
properly adjusted, the concave edge of the blade will look toward
the pubic arch, and the pivot will be directed upward and toward
the right thigh. Depressing the handle, so as to admit the intro-
duction of 4he opposite blade, place it in charge of an assistant,
and proceed to apply the other blade. Taking it in the right
hand, and with the fingers of the left hand as a guide, introduce
it, above the male branch, along the right side of the head. The
handle of this blade will lie, at first, obliquely in front of the left
groin, but is depressed as the blade is entered upward. When the
blades are properly adjusted, in the occipito-mental direction, there
will be no difficulty in locking, and the traction will be made as in
the preceding instance.

OCCIPITO-PUI3IC POSITION.

This position may include occipito-anterior positions, in which
the movement of rotation has been accomplished, and the occiput
brought to the pubic arch.

RULES FOR APPLYING THE FORCEPS.

577

In this position, the male blade will be taken in the left hand,
and with the fingers of the right hand as a' guide, must be intro-
duced within the left side of the vagina, along the left side of the
child's head, and along the left sacro-iliae symphyses. {Fig. 67.)
"When the blade is about to be introduced at the vulva, in the
direction of the axis of the inferior strait, the handle will lie in an
oblique manner over the right groin of the patient, and as the
blade passes within, being directed in a line with the pelvic axis,
the handle is gradually depressed, approaching nearer and nearer
toward the median line. When properly adjusted, the handle will
rest against the perineum, the pivot will be directed upward, and
the concave edge of the blade will be under the pubic arch. Placing
this in the care of an assistant, the fem.ale blade being held in the
right hand, and guided by the fingers of the left, must be cau-
tiously introduced,
above the male
blade {Fig. 68) as
far within the pel-
vis, over the right
side of the child's
head, as may be suf-
ficient. The han-
dle, which, at first,
was obliquely over
the left groin, is
gradually depressed
as the blade ad-
vances, and if a
proper application
has been made, the
two branches will
lock very readily,
the concave edge of
each, as well as the
pivot being directed
upward, and the
head being grasped
by the blades in the occipito-mental direction. {Figs. 69, 70.) The
traction must be made in the direction of the inferior pelvic axis,
that is, forward and downward, and as soon as the occiput is placed
under the pubic arch, and extension takes place, the handles of the

578

AMERICAN ECLECTIC OBSTETRICS.

instrument, will gradually rise upward and toward the abdomen of
the female.

LEFT OCCIPITO-POSTERIOR POSITION.

In this position the male blade will be introduced within the left
Fm. 68. lateral part of the vagina

along the right side of the
child's head, gradTlally ad-
vancing it to a proper ad-
justment as it enters. At
the commencement, the
handle will lie obliquely
over the right groin, but
as it enters it is depressed
until the blade assumesthe
direction of the occipito-
mental diameter. At first,
this direction can not be
exactly obtained, and the
soft parts at the outlet will
be pressed upon consider-
ably; the pivot of the
branch will look upward
and to the right, and the
concave edges of the
blades wiil look toward the child's forehead. An assistant holding

this, the operator will in-
troduce the female blade
within the right side of
the vagina, and along the
left side of the child's
head, and when properly
applied the two branch-
es will lock readily, with
the pivot directed to the
right and upward, and
the handles will be de-
pressed as far backward
as the parts will allow.
In both this and the suc-
ceeding position, as the
blades can not be placed exactly along the occipito-mental diameter

Fig. 69.

RULES FOR APPLYING THE FORCEPS.

579

at first, they must be gradually brought into this direction as
extraction proceeds, being careful not to bruise or injure the soft
parts of the mother, or the child's head. In all the occipito-poste-
rior positions, after rotation has been effected, and the forehead
brought to the pubic arch, the remaining delivery of the head
will be accomplished in the same manner, as mentioned in the
occipito-sacral position. And, when the head is near the inferior
strait, no attempts must be made to rotate the occiput under the
pubic arch before extracting, lest the child's neck be dislocated;
though careful efforts may be made to bring the vertex into the
hollow of the sacrum.

RIGHT OCCIPITO-POSTERIOR POSITION.

In this position the blades will be introduced somewhat similar
to the mode laid down under the right occipitoanterior. "When
the branches are correctly adjusted and lock-
ed,fthe soft parts will be considerably pressed
upon, the pivot will look upAvard and to the
left, the handles will be very much depressed,
and the blades, as in the preceding position,
will not at first be exactly in the occipito-
mental direction. (Fig. 71.) Traction and
rotation bavins: brought the forehead under
the pubic arch, the remainder of the opera-
tion will be the same as in the occipito-sacral
position.

OCCIPITO-SACRAL-POSITION.
In this position the blades are to be ap-
plied somewhat similar to the manner named
under the occipito-pubic, but with the con-
cave edges of the blades looking toward the
child's forehead instead of its occiput. When properly adjusted, the
concave edges of the blades will be directed toward the pubic
arch, the pivot will look upward, and the handles will be depressed
so far backward upon the perineum as frequently to produce a
degree of pain. The traction, in this instance, as well as in the
two preceding positions after rotation has been effected, is not to be
made in the direction of the pelvic inferior axis. The occiput
will have to be the first delivered, and to accomplish this it must
traverse over the sacrum and perineum. The handles will, there-
fore, at first, be carried upward so as to produce increased Ilex-

580

AMERICAN ECLECTIC OBSTETRICS.

ion, and bring the occipito mental diameter parallel with the axis ot
Fig. 71. the inferior strait. This will advance

the occiput over the posterior com-
missure of the vulva, when the han-
dles must be depressed in order to
permit the extension of the head to
take place, which terminates the ope-
ration.

As in these occipito-posterior posi-
tions the perineum is greatly dilated,
the operator must proceed very pa-
tiently and carefully, being especially
observant that the proper support be
given to it, as the head is passing over,
lest it be lacerated. After the occiput
has been delivered, should there be a
delay in the extension, as the instru-
ment is depressed, a sufficient degree
of traction downward and backward may be made, to enable the
forehead, face, and chin, to pass from under the pubic arch. The
rest of the labor is terminated as in ordinary cases.

LEFT OCCIPITO-TRANSVERSE POSITION.

Occasionally the head will be found lying transversely within the
pelvic cavity; the occiput may be directed toward one ischium, and
the forehead toward the other. In the present position, the occiput
will lie against the left ischium, and the forehead against the right,
in a line with the transverse diameter of the pelvis. In each trans-
verse position the rotation must bring the occiput, and consequently
the concave edges of the forceps-blades, to the arch of the pubes,
and by recollecting this, it may at once be determined how to apply
the blades.

In the left occipito-transverse position, the male blade will be
applied to the lower and left side of the child's head, after which
the female blade will be applied to its upper and right side. In
order to effect the application with as little difficulty as possible,
pass the male blade within the left lateral and posterior part of the
vagina along the left sacro-iliac symphysis, and when it has entered
sufficiently, carefully move the blade to the hollow of the sacrum,
and its concave surface will be over the left side of the child's head.
Having an assistant to hold this, introduce the female blade along

RULES FOR APPLYING THE FORCEPS.

581

the right anterior part of the pelvis, behind the right acetabulum,
and by gentle efforts work it gradually to the symphysis pubis, that
its concave surface may be applied over the right side of the child's
head. When the blades are properly adjusted, they will lock with-
out any difficulty, and the pivot will be directed toward the left
thigh of the mother.

Traction must now be made in the direction of the pelvic axis
corresponding to that part of it, however, in which the head is sit-
uated, and at the same time rotation from left to right should be
slowly and gently attempted. When this has been effected, the
remainder of the delivery will be terminated in the usual manner.

Prof. Meigs observes, that in this position, when the male branch
is introduced as above, the handle is strongly abducted toward the
left thigh and interferes with the depression, and consequently the
application of the female branch, and to avoid this difficulty, he
advises the female blade to be the first introduced. His method of
application is thus : Take the female or upper blade in the right
hand, and introduce it into the posterior and right side of the
vagina, conducting its point as near as may be to the chin, and over
the face to the right side of the head behind the pubis, leaving the
handle to project toward the left thigh. Next, take the male blade
into the right hand, and, turning the concave edge of the new curve
downward, insert the point into the right side of the vagina, below
the female branch. Let the fetal face of the clamp apply itself to
the convexity of the head, and slide it onward, and, in proportion
as it enters, make it sweep round the crown of the head toward the
back of the pelvis. In effecting this, the handle comes gradually
down as the clamp gets on the left side of the cranium, and at last
the lock is found to be where it ought to be, namely, under the upper
or female blade, with winch it is then locked." This, undoubtedly,
appears to be the better method of introducing the blades, but, as
with all other cases, the practitioner who is well versed in the gen-
eral principles of these operations will be governed by the peculiar
eircumstances attending each individual case.

RIGHT OCCIPITO-TRANSVERSE POSITION.

In this position the head lies in the direction of the pelvic trans-
verse diameter, the occiput resting against the right ischium, and the
forehead against the left. The application of the forceps is similar
to the preceding, with the exception that the female blade must be
applied to the right side of the child's head, along the posterior part

582

AMERICAN ECLECTIC OBSTETRICS.

of the pelvis, while the male blade must be over the left side of the
head and behind the pubic symphysis. The male branch is gener-
ally the first introduced, though some authors advise the female.
As before stated, it will commonly be found more advantageous to
enter that blade first, which is of the most difficult application,
being particular, however, that the introduction be so managed as
to cause no difficulty in the locking.

The same manipulation will be required, as in the preceding posi-
tion, excepting that the rotation must be made from right to left,
in order to carry the occiput under the pubic arch; this accom-
plished, the labor must be terminated as usual.

CHAPTER XLIV.

MODE OF APPLYING THE FORCEPS AT THE BRIM IN FACE PRESENTATIONS, AND IN PELVIC

PRESENTATIONS.

When the HEAD IS AT THE SUPERIOR STRAIT, the pel-
vis being of normal size, and circumstances occur requiring the
delivery to be expedited, turning should ahvays be preferred to the
use of the forceps. But when the head has engaged in this strait
and descended so low as to render the operation of turning impos-
sible, the os uteri being dilatable, and immediate delivery neces-
sary, the long forceps may be frequently employed with advantage,
even though the head has not advanced so far within the cavity,
as to enable an ear to be felt. They may likewise be applied with
benefit in cases where the antero-posterior diameter of the superior
strait is only three or three and a half inches, and the natural
efforts are insufficient to advance the head. To these conditions,
therefore, should the application of the forceps at the brim be
limited.

It must, not be supposed that an operation at the brim, with this
instrument, is an easy one ; on the contrary it is both difficult and
hazardous. The position of the head above the brim can not be
easily ascertained, and if it could be, it would make but little dif-
ference, as the forceps can be applied only along the sides of the
pelvis ; consequently, the head may be grasped by the blades in its
bi- parietal diameter, or in its occipito-frontal, the latter more fre-
quently. The mobility of the head, when not held by the brim,

MODE OF APPLYING THE FORCEPS AT THE BRIM. 583

also renders the adjustment of the blades a troublesome matter,
and frequently, their hold on the head being imperfect, as soon aa
tractiojjjp are made, the}7 may suddenly slip and seriously injure
the cervix. Hence, when it becomes necessary to use the instru-
ment at this point, the operator should proceed carefully and
judiciously.

The difference between the application of the forceps at the
brim, and at the outlet, is, that in the former, the whole hand
must be carried within the vagina, and two or three fingers be
passed as high up as possible between the cervix and head of the
child, and the instrument is to be introduced along the sides of the
pelvis, so that a blade will be applied within each ilium. When
properly adjusted they will lock more or less readily, and the
handles will be depressed backward as far as possible, that the
blades may take the direction of the superior pelvic axis. Suffi-
cient compression should be exerted on the handles to hold the
head securely, and the traction should be made, as in the other
instances, not by sudden, short jerks, nor by any forcible measures,
but by a full, slow, regular motion from handle to handle, making
tractiou in the direction of the axis of the brim.

If the instrument does not lock readily, no force or twisting
must be used to effect it, but the operator should withdraw the
blade last introduced and reapply it; and this had better be
repeated several times, than to endanger laceration of the cervix
or soft parts by forcible and unnecessary endeavors to lock the
branches.

Should the head lie with our parietal protuberance resting on
the pubis, and the other on the sacral promontory, the forceps will
be applied with one blade over the occiput, and the other over the
forehead, or, perhaps, over the face. Should the traction and
lateral motions communicated to the instrument cause the head to
take a diagonal position and descend into the pelvic cavity, the
blades may be withdrawn, provided the natural efforts are suffi-
cient to conclude the labor; if not, the blades must be readjusted,
but this time on the sides of the head.

If, after having used a justifiable force in the operation, we find
it impossible to advance the head, or at least without exerting
a power which would unnecessarily expose the mother to dangers,
it then becomes our sad duty to resort to the perforator ; and if
a delay would not add to the mother's risk, the operator can act
as soon as the stethoscope determines the child's death. We are

584

AMERICAN ECLECTIC OBSTETRICS.

never to save the life of the child at the expense of the mother's ;
and, in most cases, the death of the child can be determined by the
stethoscope in sufficient time for the mother's safety. ^

When the occiput is fastened behind the pubis, and the forehead
is in front of the sacral promontory, the blades will then pass over
the sides of the head; aud when this is ascertained to be the case,
the operator may exert more force than before, aud probably the
difficulty will be more readily overcome. When the head is locked
at the brim, Dewees advises us — after having applied the forceps —
to first elevate the head, by gently carrying the handles from side
to side, at the same time pushing the instrument upward. This
may be beneficial in some cases, but usually, where the operation
will prove successful, as the handles are rotated from side to side
with sufficient traction, the head disengages, rotates, if necessary,
to the oblique diameter, and descends into the pelvic cavity.

The forceps may sometimes be required in FACE PRESENTA-
TIONS, in which case the blades are to be applied over the ears of
the child, similar to the manner named in vertex presentations ;
being careful to so adjust them as to bring the chin toward the pubic
arch. And in all operations when the face presents, the operator
should proceed slowly, so as to permit the body to undergo a rota-
tion, and thus prevent a twisting or dislocation of the neck.

LEFT MENTO-ILIAC POSITION.— (Fig. 72.)

Fig. 72. As the chin is the part to be brought

to the pubic arch in this position the
male blade will, be passed in front of
the sacrum, and over the right side of
the child's head, as much as possible in
the occipito-mental direction. An
assistant holding this, the female
branch will be gradually insinuated
anteriorly, over the left side of the
child's head, and when the two are
properly adjusted they will readily
lock. The concave edges of the blades
will then be directed to the left of the
pelvis, and the pivot will look toward
the maternal left thigh : both of these
may also be directed upward, if, instead
of a complete transverse position, the

MODE OP APPLYING THE FORCEPS IN FACE PRESENTATIONS. 585

chin is placed somewhat anteriorly, in a line with the oblique diam-
eter of the pelvis. The handles must then be rotated from below
upward, and from left to right, gradually bringing the chin, as well
as the concave edges of the blades, under the pubic arch : this
having been effected, traction must be made directly forward and
6lightly downward, to free the chin from under the arch, after which
the handles must be slowly elevated to gradually flex the chin, and
which motion causes the head to pass successively over the hollow
of the sacrum, perineum, and posterior commissure of the vulva,
while at the same time the several parts of the face are disengaged
in succession.

RIGHT MENTO-ILIAC POSITION.

In this position the operation will be very nearly similar to the
preceding one; the female blade will be the first applied along the
posterior part of the pelvis to the left side of the child's head, while
the male blade will be carefully guided over the right side. When
correctly adjusted, they will lock, the pivot being directed toward
the mother's right thigh. Rotation will be made from below
upward and from right to left, until the chin is brought to the pubic
symphysis, when the rest of the operation will be the same as in
the one previous.

In each of these mento-iliac positions, should the face not have
arrived at the inferior strait, it will be proper to conduct it there
by tractions and lateral motions, the same as in vertex presentations;
after which operate as recommended. Some authors reverse the
order of introducing the blades, preferring to use the male blade
first, in the right mento-iliac position, and the female, first, in the
left mento-iliac. The operator will employ his own judgment in
this matter, always bearing in mind the rule to enter the blade of
more difficult application first.

MENTO-PUBIC POSITION.

The chin being placed at the symphysis pubis, and the forehead
at the sacrum. In this position, or when the face has assumed it,
the head having descended into the pelvic cavity and performed its
movement of rotation, the forceps may be more easily applied than
in the two preceding positions. The male blade must be applied
along the left side of the pelvis, grasping the right side of the
child's head, and the female blade must be passed along the right
side of the pelvis to grasp the left side of the child's head. Trac-
38

586

AMERICAN ECLECTIC OBSTETRICS.

tion forward and slightly downward must then be made, to disen-
gage the chin from under the pubic arch, after which, elevate the
handles, thereby effecting at the same time flexion and the libera-
tion of the head.

MENTO-S ACR AL POSITION.

The chin being placed at the sacrum, and the forehead at the sym-
physis pubis. This is a position with which I have never met ; and
were it not that cases have been recorded by individuals of emi-
nence and undoubted authority, I should be very much inclined to
doubt the possibility of its occurrence, except, perhaps, in case of
a very small child passing through an exceedingly large pelvis.

However, should such a position be met with, requiring the use
of the forceps, it is recommended to introduce the male blade along
the left side of the pelvis and on the left side of the child's head,
and the female blade along the right side of the pelvis on the
right side of the head. When properly adjusted, the handles will
be strongly depressed against the perineum. The face having
reached the outlet, the handles must at first be elevated so as to
pass the chin over the perineum and posterior commissure ; this
having been accomplished, depress the handles, which, with a
degree of traction, will flex the chin, and disengage the head from
its position at the pubes.

The FACE MAY BE ABOVE THE SUPERIOR STRAIT,
and movable. If the methods heretofore advised for changing it
to a vertex presentation do not succeed, and pelvic version can not
be accomplished, it has been recommended to attempt the delivery
by the forceps. This, however, will more frequently be found
impracticable, the perforator being required in the majority of
instances. When the head is thus situated above the brim, the
face usually presents in a transverse direction, and the forceps
would have to be applied with one blade over the forehead and
top of the head, and the other over the chin, pressing upon the
child's neck; so that, beside the danger of the blades slipping from
these parts, any efficient degree of compression or traction would
almost certainly occasion the death of the child.

The same may be said of those cases where the HEAD HAS
PARTLY ENTERED THE SUPERIOR STRAIT; but there is
a greater possibility of success, if the blades can be applied upon
the sides of the head; in which case the mode of application will

MODE OF APPLYING THE FORCEPS IN PELVIC PRESENTATIONS. 587

be the same as in the preceding face positions. In each of the
above conditions it will be necessary to introduce the whole hand
within the vagina, as a guide to the forceps-blades.

In the last condition, the head being partly within the cavity
and partly within the brim, but with the CHIN DIRECTED TO
THE SACRUM, and it being impossible to change the position to
a vertex presentation, or to accomplish pelvic version, it has been
recommended to slowly and carefully rotate the chin to the pubis,
as the head is made to descend by the forceps. I consider this not
only a difficult task, but almost an impossibility, at least as far as
safety to the child is concerned; and, as a general rule, when it
becomes necessary to expedite delivery in these cases, I believe it
will be found that the perforator will ultimately be required before
the labor can be terminated.

In PELVIC PRESENTATION'S, or in cases where pelvic ver-
sion has been performed, it not unfrequently occurs, that after the
expulsion of the body, there is a delay or difficulty attending the
delivery of the head, in which cases, should the accoucheur not be
able to remove the obstruction by flexing the head with his hand,
as heretofore described, he will have to employ the forceps.
Hence, as a very short delay may prove fatal to the child, the most
prudent course to adopt, in all these labors, is to have the instru-
ment at hand at as early a period as possible, after their character
has been ascertained.

In these labors, the head may be found in one of two positions,
viz.: with the occiput to the pubic arch, and the face in the hollow
of the sacrum, and which is always the most desirable position ;
or, with the face to the pubis and the occiput in the hollow of the
sacrum — a most undesirable position. If the forceps be required
to deliver the head, the rules for operating are similar to those
given in vertex presentations.

OCCIPITO-PUBIC POSITION.

In which the occiput is to the pubis, and the face to the sacrum.
Carefully envelop the arms and body of the child in a napkin, and
carry it upward, or toward the mother's abdomen, but not so far
as to endanger its neck; then, let an assistant hold the child in
this position, that its body may not be in the way of the operator.
The latter having introduced two or three fingers of his right
hand along the inferior and left side of the vagina, as a guide to

588

AMERICAN ECLECTIC OBSTETRICS.

the forceps-blade, will, with his left hand, carefully apply the blade
of the male branch upon the right side of the child's head. Then
intrust this to the care of an assistant, who will depress it some-
what to permit the application of the female blade. This will be
introduced, being held by the right hand, and guided by the
fingers of the left hand, along the inferior and right side of the
vagina, and thence upon the left side of the head. "When prop-
erly applied, the forceps-blades will grasp the head in its occipito-
mental diameter, and will lock readily. Holding the instrument
in the manner heretofore recommended, the operator will com-
mence his tractions and oscillatory movements, and as the head
emerges the handles must be gradually elevated, the same as in
occipito-anterior positions, by which the chin, face, forehead, and
vertex, successively, pass over the perineum and posterior commis-
sure, and the delivery will be thus terminated.

Should the occiput be directed to the left, or right lateral ante-
rior portion of the pelvis, the operator will be governed by the
above rules, as well as those named for occipito-anterior positions,
being careful to so introduce the blades, that, at the termination
of the delivery, their concave edges, together with the child'8
occiput, will be brought under the pubic arch.

OCCIPITO-SACRAL POSITION.

In which the face is to the pubis, and the occiput to the sacrum.
This is a very unfortunate position, and one which may prove
very painful to the female, and troublesome to the practitioner.
Although it is more frequently the result of ignorance, or want of
skill, on the part of the accoucheur, yet it will sometimes occur in
the hands of the most skillful. In this position, the body of the
child being enveloped in a cloth, as before, must be carried back-
ward, so that its back will rest against the perineum of the
mother. The blades are introduced as in the previous position, in
front of the child's thorax, the male blade along the left side of
the pelvis, and on the left side of the child's head, and the female
blade along the right side of the pelvis, and on the right side of
the child's head. The instrument being properly applied, and the
head brought to the outlet, instead of elevating the handles to pass
the occiput over the perineum, they must be strongly depressed
downward, with sufficient traction, bo as to cause the chin, face,
forehead, and vertex to pass successively from under the pubic

CRANIOTOMY.

589

arch, while at the same time the occiput is made to revolve ou its
axis, in front of, and upon the perineum.

If the occiput be directed to the left, or right lateral posterior
portion of the pelvis, the above rules, together with those given
in occipito-posterior positions, will be sufficient to guide the edu-
cated practitioner.

In addition to the preceding instances, the forceps have been
found occasionally advantageous in irregular presentations of the
head, as of the ear, forehead, etc., in which manual endeavors to
correct the position have failed; and also in some cases of dimin-
ished size of the diameters of the inferior strait. "Whatever cir-
cumstances may present during labor, requiring a resort to the
forceps, the practitioner will apply them according to the peculiar
nature of the case, being, however, always governed by the rules
already explained.

CHAPTER XLV.

CRANIOTOMY PERFORATOR CROTCHET CESAREAN OPERATION SYMPHYSEOTOMY.

Craniotomy is an operation by which the life of the child is
destroyed, for the purpose of preserving that of the mother; it is
also employed in some cases when the child is dead. The terms
embryulcia, embryotomy, and cephalotomy, have been applied to
this operation ; while the terms evisceration, exvisceration, and
exenterismus, have reference to the removal of the contents of
the trunk.

As has been heretofore named and repeated, the safety of the
mother is the first and essential consideration in the practice of
obstetrics, and if, in order to insure this, it becomes necessary to
sacrifice the child, however painful or revolting to the feelings of
the operator this unpleasant task may be, he must not shrink from
his duty, nor hesitate to adopt every measure in consonance with
the preservation of his patient. Beside, it must be recollected that
the death of the child is certain, in cases where craniotomy is
admissible; it can not be saved by any means, unless we except
the Cesarean operation, which proves fatal, on an average, to the
children once in every 3 J cases — to the mother once in every 2|-.
The operation is not to be undertaken heedlessly, nor without due

590

AMERICAN ECLECTIC OBSTETRICS.

consideration, and a proper consultation with one or more expe-
rienced accoucheurs; and is only to be attempted when both
mother and child would be destroyed, were the labor left to the
natural efforts, and when version, or delivery by the forceps can
not be accomplished, and the pelvic diameters are sufficiently spa-
cious to permit the extraction of the mutilated infant.

According to Churchill, craniotomy has been performed in Brit-
ish practice 270 times in 54,485 cases of labor, or about 1 in 201|;
in French practice 30 times in 36,169 labors, or 1 in l,205f ; in
German practice 132 times in 256,655 labors, or 1 in 1,944J. Mak-
ing a total of 347,309 labors, in which the operation was performed
in 432, or about 1 in 803f . The results to the mother have been
60 deaths in 303 craniotomy cases, or about 1 in 5. The operation,
therefore, as compared with the employment of the forceps, is less
favorable; and much of this mortality may be owing to the fact,
that the feeling and humane obstetrician being unwilling to take
the life of the child, even in so justifiable a cause, has hesitated to
perforate until assured of its death; and the delay thus occasioned
has rendered the operation much more unfavorable to the mother,
than if it had been earlier undertaken.

Perforation of the fetal skull is generally advised in cases of
diminished pelvic diameters, but the degree of this diminution is
not positively settled. Thus, Dr. Osborn considers the operation
necessary when the antero-posterior diameter is not less than 2|
inches. The smallest diameter through which a living child can
pass, is stated by Dr. Clarke, to be 3J inches; by Dr. Burns 3^; by
Dr. Le Roy 3|; by Dr. Atkin 3; by Dr. Ritgen 2; these differences
of opinion have, probably, resulted from the various sizes of the
fetal heads met with by each practioner, as well as their degree of
skillfulness in the application and use of the forceps.

As a general rule, where the superior antero-posterior diameter
of the pelvis is contracted to about three and a half inches, and
when the forceps fail to extract the fetal head, this being of usual
size, the perforator will be required; though it must be remem-
bered, that with such a pelvic measurement, there is a possibility
of extraction with the forceps. But when the extent of this small
diameter is reduced, to three inches, the forceps can be of no avail,
and craniotomy will necessarily be required. "When the pelvic
contraction is extraordinarily great, it will be impossible to extract
even a mutilated child, in which case, the Cesarean operation is
recommended. Dewees considers the operation of craniotomy

CRANIOTOMY.

591

inadmissible where the diameter measures only two inches; Baude-
locque, limits it to one and two-thirds of an inch; and Davis, to
one inch. The limit named by Baudelocque is probably the most
correct.

Craniotomy may be performed — in all cases of deformed pelvis —
whether of the cavity or of the straits, in which delivery can not
be effected naturally, or by the forceps; in cases of pelvic tumors
or other abnormal growths, which present an obstacle to the
expulsion of the child by other means— either natural or artificial ;
in cases of tedious and painful labor, when the child is dead, and
can not be removed by the forceps; in cases of hydrocephalus,
when the head can not pass through the pelvis; in cases of rup-
tured uterus, hemorrhage, convulsions, etc., where the life of the
woman is endangered, requiring immediate delivery, and where it
is impossible to use the forceps; in cases where an extremity
descends along with the head, causing an impaction which can not
be overcome by the forceps; in pelvic labors, when the head can
not be extracted by the forceps, after the expulsion, of the body;
in cases where the head, remaining within the pelvis, has been
separated from the body; and, in all cases, where from exhaustion,
irregular vertex presentations, or other conditions, the patient is
placed in imminent danger, and in which the forceps can not be
applied, or, in wTiich the circumstances of the case contra-indicate
their employment.

The practitioner who undertakes the operation of craniotomy,
must not be too hasty in his conclusions, nor in his attempts at
operating — he must be positive that it is imperatively necessary,
especially if the child be living — to destroy a living child, without
undoubted evidence that no other method will save the mothers
life, is a criminal act — it is murder. When the uterine contrac-
tions have been powerful and long-continued, without any advance
of the head, he will be justified in terminating the labor by the
forceps, if possible, or if not, by the perforator and crotchet. The
same may be said, in c;ises where, from exhaustion, uterine inertia,
or other causes, endangering the mother, and when there is little
or no hope for the preservation of the child, the forceps are
contra-indicated. Nor should the operator hesitate to act at once,
in those cases where he clearly ascertains at an early period that
the child can not be delivered except by craniotomy — as, for
instance in an enormous hydrocephalic head, in a small pelvis, in
a large head firmly ossified, etc. To delay the operation in these

592

AMERICAN ECLECTIC OBSTETRICS.

cases until dangerous symptoms manifest themselves, would be to
unjustly compromise the motheu&s life — while, prompt action,
when her system has not yet become depressed, and is capable of
more securely withstanding the shock of the operation, will be the
wiser and more prudent course.

In cases requiring immediate interference, at an early period of
labor, the operation must not be attempted until the os uteri is
sufficiently dilated and fully dilatable. In all other cases we must
be governed by the circumstances connected with them, making
endeavors to deliver by the forceps if there is the slightest chance
of these being made available.

Fig. 73. Fig. 74.

P e r f< i rator. Crotch et.

The instruments used in the operation of craniotomy, are the
perforator, or Smellie's perforating scissors, and the crotchet.
Prof. Meigs recommends the use of a perforating trocar or drill,
made especially for this purpose, and, instead of the crotchet, he
has invented two embryotomy forceps, one of which is strait, and
the other curved; each of these are serrated on their inner jaws

CRANIOTOMY.

593

to enable them to take a very sure and strong hold upon the
cranial bones, and are rounded on their sides, in order to prevent
them from taking hold of any of the maternal tissues. These he
considers superior to, and much safer than, the ordinary perfo-
rating scissors and crotchet. Other instruments have been pre-
sented to the profession, as the cephalotribe, etc., but, they are
rarely employed.

The dangers to which craniotomy exposes a female, are, injury to
the vagina or uterus, from slipping of the perforator or crotchet';
laceration of the perineum, from the employment of improper
extracting force; subsequent tendency to inflammation of the
vagina or uterus ; perforation of the bladder, especially when the
operation has been carelessly or too forcibly performed ; and the
shock to the nervous system is usually much greater than in turn-
ing, or in the use of the forceps. Instances have occurred where,
from a neglect to completely break down the brain and medulla
oblongata, the child has been born breathing and even crying.

MODE OF OPERATING. — Previous to operating, the bladder
and rectum of the patient must be thoroughly evacuated. Then
she must be placed in the
position named for a for-
ceps-operation, with the
hips over the edge of the
bed, and some cloths under
her to receive the pieces of
brain, etc., which are dis-
charged. An assistant
should place his hands upon
the abdomen, and maintain
them there, during the
whole of the operation, to
fix and steady the uterus.
Anaesthesia may be pro-
duced, if the patient be in a
condition not contra-indica-
ting it; though, I should
adopt it with considerable
hesitation, from the fact,
that extensive injury might
be done to the maternal tis-
sues while she lies in an un-

594

AMERICAN ECLECTIC 0BSTETRIC8.

conscious state, and no timely warnings could be made to announce
to the operator when the danger from this circumstance commenced.

Introduce two fingers of the left hand within the vagina, and
carry them upward until they come in contact with the part to be
perforated. This should be the most depending portion of the
head, and a suture or fontanelle should be avoided, because after
the perforation is effected in one of these, the opening becomes
closed from a collapse of the cranial bones. Then carry the per-
forator, which must be warmed and greased, carefully along the
inside of the fingers, being particular not to injure any of the parts
of the mother, until the sharp point comes in contact with the part
selected for the incision.

Still guarding the instrument from slipping or injuring the mother,
press it firmly but moderately, against the fetal skull, at the same
time giving to it a rapid boring or semi-rotatory motion; a few
FIG yg. motions will suffice to pierce the

bone, which may be known by
the cessation of any further re-
sistance. {Fig. 75.) Then push
up the scissors until the shoul-
ders or rests at the base of each
blade, prevent their further ad-
vance. Holding one branch ot
the instrument firmly, with the
thumb passed into its eye or
ring, the fingers ot the other
hand still protecting the mother
from injury, by being placed
upon the ellqows or rests as they
move, to ascertain that they do
not leave the skull — an assistant
will take hold of the other
brunch, and separate it from its
fellow to an extent of three
inches, and which will cause the
blades to make an incision about
an inch long. {Fig. 76.)

Then, without withdrawing
the instrument from the vagina,

t turn it round, and place its

point upon the outer surface of the skull, so as to form another

CRANIOTOMY.

595

incision at right angles with, the first, and crossing it, and which is
to be done in a similar and guarded manner, as before. This having
been accomplished, pass the blade through the crucial incision,
within the skull, and thoroughly break down the brain, by alter-
nately opening and shutting the blades, and turning them rapidly
ronnd in various directions ; and be sure to cut across the medulla
oblongata, so as to completely destroy the life of the child. The
scissors will now be withdrawn, together with the fingers covering
their cutting edges.

If there exists no necessity for immediate delivery after the
destruction of the brain, the operator may wait a reasonable time
to ascertain whether the natural powers will be sufficient to termi-
nate it. But if the operation has been commenced after symptoms
of exhaustion, or other serious symptoms have manifested them-
selves, he will proceed without delay, to finish the labor.

Reintroducing the fingers of the left hand, the crotchet, having
been previously' warmed, must oe passed along them into the cra-
nium, and if the breaking douw pIG 77
of the cerebral mass was not com-
pletely effected by the scissors,
it may now be by the crotchet.
After which, insert the point of
the crotchet on the internal sur-
face of the bone, keeping a finger
of the left hand upon the head
externally, and opposite to the
inserted point of the instrument,
in order to cover it, and prevent
injury to the maternal parts,
should it slip, or break through
the bone. {Fig. 77.) Protecting
the surrounding parts from in-
jury, by folding the scalp over
the edges of the bones, the prac-
titioner will, by a gradual, steady
force, applied in the direction of
the superior pelvic anteroposte-
rior diameter, commence the ex-
traction of the bones. He must not pull by jerks or he will frac-
ture the bones, and the traction must be made during the pains, or
if these are absent, they should be imitated by allowing intervals

596

AMERICAN ECLECTIC OBSTETRICS.

from time to time during the extraction. Whenever the bone
breaks under the crotchet point, this must be applied to some other
resisting part of the skull.

Frequently, the bones will break and come away by pieces, and
then great care should be observed in removing them, whether by
the fingers, or the bone forceps made for this purpose. If the
head does not pass readily, or if a secure purchase can not be made
with the crotchet, Meigs' embryotomy forceps may be used ; or, if
delay be not contra-indicated, the structures will become weakened
after some hours, which will reuder them of more easy extraction.
But I consider prompt delivery, after perforation of the skull, the
better and safer method in all cases.

Some writers recommend the craniotomy forceps, which are to
be used by passing one blade upon the inner surface, and the other
FIG 73 upon the outer surface of the skull,

so as to take a firm and secure hold,
and then make traction at inter-
vals, the same as with the crotchet.
{Fig. 78.) After the birth of the
head, it should be covered with a
cloth, and if there be a delay in the
advance of the shoulders, traction
may be made upon the neck in the
direction of the axis of the brim,
or a blunt hook may be passed
under one, or each axilla, to facili-
tate their expulsion. Sometimes,
the trunk will not advance, when
it will become necessary to perfo-
rate the chest and remove its con-
tents, as well as those of the abdo-
minal cavity, extracting the ribs
by the crotchet, somewhat simi-
lar to the removal of the cranial bones.

In case of a separation of the head from the body, the latter
being delivered, the forceps will require to be applied in order that
the head may be held firmly, while the perforator is being used to
reduce its size.

After the operation, keep the patient quiet, overcoming the ner-
vous shock by the compound powder of Ipecacuanha and Opium,
or some similar preparation, and the vagina may be occasionally

CESAREAN OPERATION.

597

cleansed by injections of warm water. Should symptoms of
inflammation set in, promptly remove them by the proper meas-
ures.

CESAREAN OPERATION. The Cesarean section, or hysterot-
omy, is a less favorable operation to the mother than either of the
preceding, and, consequently, is never to be attempted for the pur-
pose of delivering the child, except as a last resource. Though
a simple operation, it is exceedingly dangerous, and should never
be undertaken except upon justifiable grounds. According to sta-
tistics— which are hardly reliable, from the fact that the cases
reported are generally the successful ones, a number of the unsuc-
cessful being suppressed — about one mother in two and one-third
is saved, and about one child in three and one-third.

The operation is resorted to with a view of effecting delivery
with safety to the mother and her offspring, in those cases, where
it is impossible to deliver through the natural passages, either by
the forceps or perforator. In a pelvis whose superior antero-pos-
terior diameter does not exceed one and a half inches, it will be
almost, if not quite impossible, to extract even a mutilated child,
without powerful efforts, exposing the mother thereby, to at least
as serious results, as would be likely to follow this section. And
in such cases the operation will be required whether the child be
alive or not. Mollities ossium, or the presence of tumors or other
abnormal growths within the pelvis, reducing its diameters, and
preventing the advance of the child, may render a resort to this
operation necessary, especially when they can not be removed or
lessened in size, by other means, heretofore referred to.

When the mother has died suddenly during labor, the child
being still alive, the Cesarean operation has frequently been the
means of saving it; and in order to afford it every opportunity
of being saved, the operation should be performed as promptly as
possible.

The dangers to which the Cesarean section exposes the female,
are, hemorrhage, both from the uterine and abdominal bloodvessels,
though fatality from this cause occurs less frequently than was
formerly supposed; subsequent inflammation of the uterus, or
peritonitis; death from the shock to the nervous system; and,
strangulation of a portion of the intestines, which may be held
between the lips of the external incision, or, that made in the
uterus.

598

AMERICAN ECLECTIC OBSTETRICS.

The earlier the operation is performed, the more favorable will
it be for the mother, because her strength will be less impaired
than after a prolonged uterine action ; and in cases, where it is
positively known that the operation must be performed before
delivery can be effected, it should be undertaken at the com-
mencement of labor. The period named by authors as the most
favorable for operating, is either before, or immediately after the
rupture of the membranes, and the longer the operation is delayed
after this has taken place, the more unfavorable will it be for the
mother.

Several cautions are given, by those who have performed the
operation, which it is necessary to be mindful of; according to
Ramsbotham, these are: 1st, to avoid dividing the tendinous expan-
sion of the recti mussles forming the linea alba, because from its
low degree of organization it would not be so apt to heal as kindly
as the muscle itself; 2d, to avoid making the incision so far toward
the side as to run the risk of wounding the epigastric artery; 3d,
to expose the naked surface of the uterus no longer than is abso-
lutely required, being especially careful to handle the organ as lit-
tle as possible; 4th, to avoid making the incision at the side of
the uterus, or at that part of the organ to which the placenta is
attached, on account of its being the most vascular part, and which
may be ascertained by the stethoscope ; 5th, to avoid wounding
the child when incising the uterus; Gth, not to allow much time
to elapse between the extraction of the child and that of the pla-
centa ; 7th, be especially careful that none of the intestines become
included with the lips of either incision, as the risks of strangula-
tion would be added to those of the operatiou.

MODE OF OPERATING.— Having previously emptied the
bladder and rectum, the female is to be placed upon her back,
with her shoulders and head elevated by pillows; she may be in
bed, or upon a table with a mattress on it, and may lie lengthwise,
or with her hips brought to the edge of the bed, the feet hanging
down toward the floor. Ramsbotham advises the temperature of
the room to be brought to at least 80° Fahrenheit. In order to
avoid injury to any of the uterine appendages, the uterus must be
brought in the median line, and kept there by the hands of an
assistant being placed over it; and to prevent any part of the
intestines from insinuating themselves between the uterine and
abdominal walls, a second assistant may make pressure with one
hand over the uterine fundus. An incision of about six inches in

CESAREAN OPERATION.

599

length is now to be made through the abdominal walls, extending
from a short distance below the umbilicus, to within about two
inches of the pubes, as a further extension of it would endanger
the bladder. The incision may be made a little to the left or right
side of the linea alba, as the operator may determine. The parts
should be carefully divided as far as the peritoneum, into which a
small aperture is to be cautiously made, sufficiently large to admit
the introduction of the index finger of the left hand as a director
for a probe-pointed bistoury, and to prevent it from wounding the
intestines. The peritoneum must be divided until the incision is
of the same dimensions with that of the integuments above, when
the uterus will be brought into view. An incision is now to be
made into the uterus, carefully dividing layer after layer, until the
placenta, or the membranes are brought into view, and which lat-
ter may be known by their transparency. Make a slight opening
into the membranes, if these have not been ruptured previously,
and by means of pieces of soft sponge remove some of the liquor
amnii, or it may be more quickly removed by a proper syringe.
Then enlarge the orifice in the membranes, withdraw the child, tie
the cord, and extract the placenta and membranes, having first
twisted them into a cord. Should the placenta, however, present
first, it must not be divided, but detached at one side that the
membranes may be reached.

When the membranes are ruptured, the assistants must be care-
ful, in holding the lips of the wound apart, that the abdominal
and uterine walls are kept in contact with each other, that none of
the amniotic liquid may pass between them into the abdominal
cavity. After the removal of the child, the uterus commonly con-
tracts and detaches the placenta; but if this be not effected, it
must be accomplished artificially. The operator must also ascer-
tain that the canal of the cervix is free, in order that the lochia
may escape, and this may be learned by passing a finger through
the os uteri from the wound, and one or two of the other hand,
per vaginam.

Any blood or other foreign body which may have passed within
the uterine cavity, must be removed, and the wound in the organ
must be well cleansed. The contraction of the uterus generally
brings the lips of the wound in opposition, so that no sutures will
be required, and there will be but little hemorrhage. Should any
blood have escaped into the abdominal cavity, remove it by lightly
sponging; and, while an assistant retains the intestines in their

600

AMERICAN ECLECTIC OBSTETRICS.

place, close the wound in the abdomen by as many sutures as may
be necessary, leaving a space at the lower part for the exit of the
fluids, which escapes from the abdomen. Between and over the
sutures, strips of adhesive plaster should be applied, over which a
common compress, either dry, or moistened with cold water, must
be placed, the whole being kept in position by a bandage drawn
moderately tight.

Blundell suggests the propriety of rendering the Fallopian tubes
impervious, by removing a small portion of their substance on
each side, during the operation, thereby preventing the possibility
of conception, without destroying the sexual appetite.

During the operation, and immediately after, the condition of the
patient may render the administration of cordials necessary.
When she has been placed in bed, administer an opiate, and treat
the case on general principles to lessen irritability, and prevent or
allay any febrile or inflammatory symptoms which may come on,
treating them promptly and energetically. The patient must be
kept quiet, visitors must be excluded from the room, which should
be kept rather cool, and any inflammation along the edges of the
incision must be at once reduced by cold water, or fomentations, as
seems best suited to the case. Small doses of tincture of Aconite
root, with or without tincture of Gelseminum, will aid considerably
in averting inflammation. The diet must be exceedingly light, and
the utmost care and attention should be bestowed upon the female.
The child should be fed until the mother is beyond danger, and in
the meantime the milk, should any be present, may be removed
by a young puppy, or by a pump made for this purpose.

It is always proper to have warm water on hand, in order to
place the child in it, should animation be suspended.

The operation of SYMPHYSEOTOMY, or an artificial separa-
tion of the pubic bones at their symphysis, has been advised in
cases of excessive deformity of the pelvis ; but as I can not con-
ceive of a case in which it would be justifiable, being attended
with many dangers, I shall not enter into any description of it.

A necessity for the operations above-named, may frequently be
obviated, where the pelvic measurements are known to be too
small, by the induction of premature delivery, or even, in some
cases, of abortion.

INDUCTION OF PREMATURE LABOR.

601

CHAPTER XLVI.

INDUCTION OF PREMATURE LABOR.

In cases where it is known that the fetus, at full term, would be
unable to pass through the pelvis, either naturally or by the aid of
forceps, owing to a deformed condition of the pelvic bones, the
INDUCTION OF PREMATURE LABOR is recommended ; an
operation which has for its object the safety both of the mother
and her child. This operation originated in England, where it has
been practiced since 1756, at which time, we are told by Denman,
a consultation of most eminent practitioners in London was held to
determine the question of its morality, safety, and utility ; which
having been decided affirmatively, the operation was first success-
fully performed by Dr. Macaulay. From England it was carried into
Germany in 1799, by A. Mai, but was not practiced until in 1804,
by "Wenzel. In France, it was not performed until 1831, by Stoltz,
having previously met with much opposition as an immoral and
criminal procedure. At this time, however, it is considered by all
obstetricans as a perfectly justifiable operation.

The induction of premature labor consists in exciting the uterus
to contract, leaving the subsequent expulsion to the natural efforts -
consequently, it differs from a " forced delivery," in which nearly
the whole process is conducted by artificial means. It is not
to be attempted until at the period of fetal viability, or during
the seventh or eighth months. Its intention is to safely deliver
the living child, instead of waiting for the natural term, to
destroy it by the perforator, and thus expose the mother to much
risk; and, also, to save the mother from the hazardous Cesarean
operation.

It has been objected, that it is impossible to accurately determine
the relative proportions existing between the fetal head and the
female pelvis. This is a very trifling objection, and one that
should bear no weight at all in the consideration of the ques-
tion of operating ; because these points may be determined with
sufficient accuracy for all practical purposes, by the various
methods heretofore explained; and should we, even, arrive at a
wrong estimate in these measurements, it would be of no great
importance ; I consider the following reasons, given by Velpeau,
as correct, and of much value — he says : " If the pelvis be wider
39

602

AMERICAN ECLECTIC OBSTETRICS.

than we thought, premature delivery (at, or after the seventh
month), is accomplished without risk. If, on the contrary, the
narrowing be more considerable, the fetus will certainly perish ;
but then, had no operation been attempted till the full term, the
fetus would equally have been lost, and the mother would have run
greater risk."

But whatever may be the objections raised against this opera-
tion, it must always be borne in mind that the results are not so
serious to either mother or child, as when pregnancy is permitted
to proceed to its full period. Thus, where craniotomy is performed,
not only are the infants destroyed, but one in five mothers are lost;
where the Cesarean operation is achieved, the children die in the
proportion of one in three and a half, and the mothers of one in
two and one-third. Where premature labor is effected, more than
half of the children are saved, while only one mother in sixteen is
lost. In 161 cases of premature delivery, given by Velpeau, eight
died, five of which perished from causes not connected with partu-
rition ; in 280 cases, given by Figueira, only six were lost. Here,
then, are 441 cases of premature delivery, of which only nine died,
or about one in fifty. What sane man can, with these results
before him, morally or religiously object to an operation so highly
favorable to both mother and child ?

The induction of premature labor, in cases of malformed pelvis,
is to be effected only when the small diameter of the superior strait
ranges between two and a half and three inches ; under which cir-
cumstances it would be impossible for the full developed fetal head
to pass naturally, or even with the aid of the forceps. At seven
months, according to the researches of several eminent obstetri-
cians, the bi-parietal diameter of the fetal head is from two and
a half to two and three-quarter inches, or not quite three inches,
and consequently it may pass very readily through a pelvis the
smallest diameter of which is contracted to a measurement between
two and a half and three inches : a smaller pelvic diameter than
this would render the passage of the fetal head impossible even at
the seventh month, unless it should be a very small one ; but as
we have no means of determining this while the fetus is yet within
the uterus, the practitioner is necessarily bound to govern himself
by the standard measurements as given. The following approxi-
mate measurements of the fetal head have been given by M.

INDUCTION OF PREMATURE LABOR. 603

Figueira, and will undoubtedly be of some utility to the practi-
tioner :

Age of the Fetus.

Bi-parietal
Diameter.

Occipito-frontal
Diameter.

(Occipito-bregmatic
Diameter.

Inches. Lines.

Indies.

Lines.

Inches.

Lines.

7th month.

2

9

3

8

2

10

U do.

3

3

9

3

8th do.

3

1

3

10

3

1

8£ do.

3

2

4

3

2

9th do.

3

4

4

3

4

[See dia7neters of fetal head, page 51.)

Eitgen has given a table of some practical value, relative to the
time at which premature delivery may be effected ; thus it may be
induced at the

Inches. Lines.

29th week when the antero-posterior diameter of the pelvis is 2 7

30th " * " " « .*< 2 8

31st " « " " " " 2 9

35th " * " " " H 2 10

36th " " " " " " 2 11

37th " " " " « « 3 0

Mi Stoltz has given the bi-parietal diameters of the fetal head to
be from the

32d to the 33d week of pregnancy, 2| inches.
34th " 35th ■ " 3J "

36th " 37th " " 3£

The rule given by some authors is, when the antero-posterior
diameter of the superior strait measures three inches, to delay the
operation until the 38th week or eighth month ; when it measures
but two and three-quarter inches, operate at 7J months; and when
only two and a half inches, operate at the 7th month. If the
diameter is less than two inches, an attempt must be made to save
the mother's life either by abortion or the Cesarean operation ;
and I should not hesitate a moment in resorting to the former
method, which every accoucheur must acknowledge as being less
hazardous in its results than the latter.

In cases where the antero-posterior diameter of the superior
strait is ascertained to be three and a quarter inches, and where in
previous pregnancy the fetus could be delivered only by a resort
to embryotomy, the practitioner is justified in effecting premature
labor; but not in primiparse, with whom deliver}7 is usually pos-
sible, even under such circumstances, and with whom it is not

604

AMERICAN ECLECTIC OBSTETRICS.

advisable to operate when the diameter measures beyond there
inches. And in all instances the practitioner should be well
assured of the life of the fetus before attempting the operation,
bearing in mind that the longer the child is allowed to remain
within the uterus, compatible with its safe delivery, the greater
will be the chances in favor of its living subsequently. If the
existence of a twin pregnancy be satisfactorily ascertained, the
operation may be dispensed with, because the development, as well
as organization of twins, is usually less perfect than in single
pregnancies; but from the difficulty in determining twin pregnan-
cies, this rule will seldom prove of any practical importance.

There are other conditions beside that of pelvic contraction, in
which the induction of premature labor may be justifiable; as for
instance, in cases of excessive vomiting, where no food can be
retained upon the stomach, notwithstanding various remedial
agents have been administered, and where consequently the life of
the mother is threatened by starvation. It is likewise proper in
all cases where the continuance of pregnancy adds to the dangers
which threaten the life of the female, as in aggravated diseases of
the heart; in aneurism, where, from the obstruction to the general
circulation occasioned by the enlarged uterus, a rupture of the
aneurismal tumor is feared; in strangulated hernia; in excessive
serous effusions; in convulsions, especially where they resist the
remedial means pursued and recur frequently, becoming at the
same time more and more severe; in uterine hemorrhage, more
particularly when owing to the attachment of the placenta over
the iuner os uteri (placenta prsevia); in diminution of the bis-
ischiatic diameter; in abdominal or uterine tumors, which inter-
fere with the development of the uterus or the delivery of the
fetus at full term; in case there has been a rupture of the uterus
in a previous labor; and, indeed, in all cases where the life of the
mother is at stake, and can not be saved by any other means. A
dead fetus is not of itself a cause for the operation, unless there
be other circumstances of a hazardous character attending it.
But whatever may be the nature of the case, it must not be for-
gotten that the practitioner who attempts this operation assumes
a very heavy responsibility, one in which a failure, or a fatal result
to the mother, may seriously involve his reputation for a lifetime;
consequently, as a general rule, and more particularly among
young practitioners, no operation of the kind should be under-

INDUCTION OF PREMATURE LABOR. 605

taken without a consultation in the matter, and the sanction of
the consulting physicians.

Denman says: "There is another situation in which I have
proposed and tried with success the method of bringing on prema-
ture labor. Some women who readily conceive, proceed regularly
in their pregnancy until they approach their full period, wheu,
without any apparently adequate cause, they have been repeatedly
seized with rigor, and the child has instantly died, though it may
not have been expelled for some weeks after. In two cases of this
kind I have proposed to bring on premature labor when I was cer-
tain the child was living, and have succeeded in preserving the
life of the children without hazard to the mother. There is
always something of doubt in these cases, whether the child might
not have been preserved without the operation; but as such cases
often come under consideration, and as I am disclosing all that my
experience has taught me, it seemed necessary to mention this cir-
cumstance." I would remark here that I have seen similar cases,
occurring especially after a bleeding for fullness of the head or
other unpleasant symptom; but whether they were occasioned by
the bleeding I am not prepared to say, but make the suggestion
for future investigation: again, I have witnessed a few instances
where no bleeding has been performed.

Females sometimes, in a succession of labors, give birth to still-
born children, and which is owing, not to pelvic malformit}r, but
to a preternatural energy of the contractions of the uterus, very
similar to those induced by Ergot, being permanent, and by con-
stant compression of the cord causing a suspension of the fetal
circulation. Premature delivery has been recommended in such
cases, with an intention of lessening the energy of the uterine
action, or a hope of finding it less powerful at the seventh or
eighth month, in consequence of which the child may probably be
saved. But the operation is not justifiable. The disposition to
excessive uterine contraction may be overcome by the employment
of uterine tonics and antispasmodics during pregnancy; and
anodynes during parturition, with rectal injections of the officinal
compound tincture of Lobelia and Capsicum, slightly diluted with
warm water, and in very severe and obstinate cases, a portion of
this tincture may also be administered internally, or the tincture
of Gelseminum.

It can not be denied that there are several difficulties which

606 AMERICAN ECLECTIC OBSTETRICS.

interfere in a greater or less degree, with the success of the opera-
tion ; thus, the size of the pelvis may be inaccurately estimated,
and the operation be performed at too late a period, or too early, to
insure the subsequent existence of the child. Frequently it is
almost if not quite impossible to precisely determine the age of
the pregnancy, as women are very apt to be mistaken in their cal-
culations, and the results may be similar to those just mentioned
above ; but notwithstanding these difficulties, they are by no
means of such a nature as to lead us to reject the operation, the
results of statistics beiug greatly in its favor. Again, abnormal
presentations, as of the shoulder, breech, etc., are more frequent
in premature labors, for which no satisfactory reason has been
given, and which generally prove fatal to the child, owing to the
constant pressure on the umbilical cord during the passage of the
fetal head through the brim; or, where the presentation is natural,
the fetus may be destroyed by a long-continued compression of
the uterus upon it, owing to the escape of the water and the delay
in dilatation of the os uteri. But none of these obstacles are of
so grave a nature as to prohibit the opration, because the life of
the mother is to be considered as of the first importance, and that
of the child as secondary — to be saved, if possible, but always
without endangering the mother.

I would refer here to an ancient prejudice which is still very
popular, and is even supposed to be true by many physicians ; it
is, that a child born at the seventh month is more apt to live, than
one born at the eighth month of pregnancy. This, however, is
very absurd and incorrect; for we would suppose that the longer
the intra-uterine life is extended, the greater would be the chances
for a perfect development of organization, and consequently of a
subsequent independent existence, and such is actually found to be
the case in practice. I am aware that " eighth month children," as
they are called, frequently die at a very early age, and I am like-
wise aware that "seventh month" and "ninth month children"
frequently meet with a similar early death ; but I have found no
peculiar tendency of this kind among those born at the eighth
month.

Various methods have been devised and recommended for the
premature expulsion of the fetus, some of which may prove safe,
as far as the mother is concerned, but are necessarily fatal to the
child; while others have in view the safety of both mother and

INDUCTION OF PREMATURE LABOR.

607

child. The former are seldom employed unless the intention is to
produce abortion, previous to the seventh month or viable condition
of the child ; and it should never be attempted unless the antero-
posterior diameter of the superior strait is less than two and a half
inches. In these cases the question is between abortion and the
Cesarean section ; by the former the child is delivered dead, while
the hazard to the mother is comparatively small ; by the latter, the
child has one chance in three of living, while the mother has but
one in two and a quarter chances of recovering from the operation.
Shall we then sacrifice the child to save the mother, or the mother
to save, probably, neither? My own view of the matter corre-
sponds with that of Velpeau, who says : " As regards myself, I avow
I can not put in comparison the precious life of a fetus of three,
four, five or six months, a being scarcely differing from a plant, oue
that is bound by no ties to the external world, with that of an
adult woman, whom a thousand social relations interest us to save ;
therefore, in a case of extreme narrowness of the pelvis, and where
it was mathematically demonstrated that delivery at the full period
was impossible, I would not hesitate to recommend producing abor-
tion in the first months of gestation."

Abortion may in some cases be effected by warm pediluvia, copi-
ous sweating, and drastic purgation, while in others these will pro-
duce no influence at all ; indeed many unchaste females are in the
habit of producing abortion in the early months of pregnancy
whenever this takes place, by such means as named above, yet it
is generally accomplished at a great sacrifice to both health and
long life. The oil of Savin given in doses of ten drops on sugar, and
repeated three times daily for a week or two, will cause abortion,
especially in the early months of gestation, in consequence of its
destructive influence upon the ovum, yet it frequently fails, and if
given in larger quantities is very apt to produce serious inflamma-
tion ; its action appears to be more positive in females of a strumous
diathesis. Borax and Cinnamon in doses of five grains each, or a
mixture of Borax and Ergot, each, in powder, ten grains, powdered
Cinnamon one scruple, administered three times a day, will like-
wise often occasion abortion, by their influence upon the contrac-
tile tissue or action of the uterus, yet these compounds sometimes
produce irremediable and distressing symptoms. Many other
agents have produced abortion as various essential oils, or infusions
of emmenagogue herbs, with or without the addition of Yeast, etc.,
but none of these can be recommended as invariably certain in

608

AMERICAN ECLECTIC OBSTETRICS.

their results, beside which, they often produce disastrous conse-
quences.

Probably the safest as well as the most certain method is the one
pursued by Macaulay in 1756 — perforation of the membranes by the
introduction of a catheter or a canula armed with a trocar ; the
instrument is introduced into the os uteri, and the membranes pierced
by it, care being taken not to injure the parts of the mother. This
method is neither painful nor injurious to the mother; by it, the
amniotic liquid escapes, the uterine walls retract, dilatation of the os
uteri more or less slowly ensues, requiring from twenty to forty hours,
and in some instances even sixty ; the uterus, irritated by the con-
stant proximity of the fetus, contracts, but is unable to expel its
contents until the os uteri has become sufficiently dilated, hence there
is frequently excessive hemorrhage from an early detachment of the
placenta. This method has been also advised to induce premature
delivery, but it should never be adopted after the seventh month, as
from the early discharge of the waters and consequent prolonged
pressure of the uterus upon the fetus, its life is greatly endangered.

The above methods are among those which have been used at
various times for the purpose of producing abortion, but in instances
where it is required to save the life of the child, if possible, that is,
after the seventh month, other measures have been recommended,
among which may be mentioned the following :

1. Frictions over the fundus uteri to induce contractions, at the
same time titillating or irritating the os uteri by one or more
fingers introduced into the vagina, has been proposed by D'Outre-
pont and Ritgen ; this plan, however, is rarely employed, because it
seldom effects any uterine contractions, and when these do occur,
they are too feeble and evanescent to produce an expulsion of the
fetus.

2. It has been suggested by Dr. Hamilton, to introduce a finger
or gum-elastic catheter beyond the inner os uteri, and separate the
membranes from the internal uterine surface for some two or three
inches around, and where labor can be brought on by this mode, it
is safe to both mother and child. But it can not be relied upon as
an efficient measure, and in cases where it has succeeded, the result
was probably brought about by the irritation produced at the
cervix.

3. M. Meissner, of Leipsic, has given a plan by which he assures
us that, in fourteen cases upon whom it was tried, both mother and
child were saved in every instance ; it is an improvement upon the

INDUCTION OF PREMATURE LABOR.

609

method of Macaulay, and has tor its object the gradual discharge of
the amniotic liquid, thereby avoiding long-continued pressure upon
the fetus. The plan is to puncture the membranes, not at their
lowest part, but high up, as near the fundus uteri as possible; and
the instrument he employs is a canula about thirteen inches in
length, and two lines in diameter, and having a curve correspond-
ing with the segment of a circle whose radius is eight inches.
Attached to this canula are two stilets, one bearing at its extremity
an olive-shaped button, the other a trocar; a ring is also placed
upon the lower extremity of the convex side of the canula, which
enables the operator to determine the direction of the curvature
when the instrument is within the uterus. The female being placed
in an erect position, the operator, stooping down on one knee, pro-
ceeds carefully to introduce the canula armed with the olive-shaped
button through the os uteri, and as far up between the membranes
and uterine walls as possible, say six, eight, or ten inches above the
os uteri. This having been accomplished, and also having ascer-
tained that the point of the canula is not in contact with any part
of the fetus, the button stilet is withdrawn, and that with the trocar
introduced and the membranes punctured. Sometimes, when the
cervix is high up, and looking so far backward as to be reached
with difficulty, the female will have to sit on the edge of a chair, or
assume the recumbent position, in order to enable the practitioner
to introduce the canula. After the perforation of the membranes,
the trocar-stilet is removed, a small portion of fluid is permitted to
pass through the canula, and then this is also withdrawn. The
waters by this mode escape gradually, pains usually come on in
twenty-four or forty-eight hours, and labor is finished in from thirty-
six to sixty hours. This operation has not been very extensively
employed, but is preferable to any of the plans heretofore named.

4. Huge has proposed a mode of inducing uterine contractions
without puncturing the membranes, by the introduction of a sponge
within the os uteri. The sponge must be soft and fine, of a conical
shape, about two inches long, and half an inch in diameter at its
base, and a piece of tape must be attached to its base, by means of
which it may be removed when required. It may be prepared by
soaking a piece of fine sponge in a solution of Gum Arabic, wrap-
ping it round an awl, and tightly binding it on by a string ; when
dry, it can be cut into any required shape. The female, for a few
days previous to the operation, is directed to use the warm-bath, and
warm emollient and narcotic vaginal injections ; and before intro-

610

AMERICAN ECLECTIC OBSTETRICS.

duciug the sponge, both the rectum and bladder are to be emptied.
She is then to be placed in a position somewhat similar to that
required for the application of the forceps, and the finger of the
operator is introduced into the vagina as far as the os uteri to serve
as a conductor; with the other hand, a long pair of forceps, holding
the piece of sponge, is to be passed along the conducting finger and
gradually entered within the canal of the cervix. After holding it
there for a few minutes the forceps are to be withdrawn, and the
sponge kept in its place by filling the vagina with a large sponge, or
pieces of linen, and the whole retained by a proper bandage ; the
patient is then directed to remain in bed. The fluids of the parts
saturate the sponge, which swells up, and consequently dilates the
os uteri, and irritates its fibers, which, reacting upon those of the
corpus uteri, effects contractions, which usually occur in five or six
hours. If, in the course of twenty-four hours, active contractions
of the uterus are not excited, the sponge must be removed by means
of the tape, and a new and larger piece inserted in its place; this
second application is most generally successful. If required, the
labor-pains may be increased by titillating the cervix, frictions over
the abdomen, and the use of (Caulophyllin or) Ergot. This plan is
certainly preferable to that of puncturing the membranes, yet, it is
stated to fail occasionally.

Professor Kiwisch, of Wurzburg, recommends the direction of
a stream of warm water from a hight, by means of a syphon, con-
tinuously upon the os uteri ; Dr. Smith proposes to improve upon
this method by alternating the temperature of the douche from
hot to cold. A vessel capable of holding two gallons of water is
placed at an elevation of four or five feet above the patient, to
which is affixed a flexible tube about eleven feet in length and half
an inch in diameter, the uterine extremity of which terminates in
an ivory or bone nozzle five or six inches in length, or is connected
with the straight tube of an injecting apparatus, and near the upper
end of which a stop-cock is attached. In employing this, two gal-
lons of warm water, about 110° I\, are to be placed into the vessel.
The uterine extremity of the tube is then passed into the vagina
and directed toward the os uteri, the female being in bed, or in an
empty hip-bath; holding the tube steadily, the stop-cock is turned,
and the stream immediately commences flowing with considerable
force against the os uteri, and which is to be continued until the
whole two gallons have been discharged. If this is to be followed
by a cold douche, the same quantity of cold water is to be poured

INDUCTION OF PREMATURE LABOR.

611

% into the vessel as soon as it is emptied, and allowed to flow in the
same manner. The time occupied in the operation is from twenty
to thirty minutes, and the only disagreeable sensations experienced
are when the warm and cold currents first begin to run. This
operation may be repeated two or three times daily, requiring its
application from two, to four, eight, or twelve times. It is to be
preferred to all others yet named, as its application is simple, and
no possible injury can be done to either the mother or child. If
expedient, it should be performed at the period in which the cata-
menia would have appeared in the non-pregnant condition. A
syringe capable of maintaining a continuous stream may be sub-
stituted for the vessel and tube.

6. The employment of galvanism or electro-magnetism, as sug-
gested by Herder in 1803, has been found efficacious in bringing
on uterine contractions, even after other means had failed. This
is accomplished by placing one pole of the battery on either side
of the uterus, continuing the application of the current for half an
hour or an hour each time, and renewing it once or twice daily;
the ordinary electro-magnetic apparatus in use is the best form, as
repeated shocks prove more effectual and certain in stimulating
the uterus to contractions than a continued current. In applying
the poles it will be proper to attach to the discs a sponge moistened
with water, or salt and water; or pieces of thin flannel likewise
moistened may be placed between the discs and the abdomen.
Some apply one pole to the neck of the uterus, and the other to
the spine or abdomen, immediately above the fundus; but this is
unnecessary. Dr. Radford states, "that galvanism not only orig-
inates the temporary contractions of the uterus, but also produces
such a lasting impression on the organ that pains continue to occur
until the labor is terminated. It produces severe pains in the loins,
and great bearing down, followed by dilatation of the os, and
expulsive pains." I have employed this agent in a few cases, and
with invariable success, though the number and intensity of the
applications had necessarily to be varied in each. In relation to
its influence on the fetus, Dr. Radford, who has made extensive
employment of it in midwifery, states that he has never observed
that the child in utero has been injured by its use, which gives it a
great advantage over the administration of secale cornutum, which,
in many cases, is destructive of it; he also remarks, "Galvanism
is especially advantageous as a general stimulant in all those cases
n which the vital powers are extremely depressed from loss of

612

AMERICAN ECLECTIC OBSTETRICS.

blood. Its beneficial effects are to be observed in the change of
countenance, restoring an animated expression ; in its influence on
the heart and arteries ; in changing the character of respiration ;
and its warming influence on the general surface. I have several
times observed, in cases in which other powerful stimulants have
failed to produce any beneficial results, the most decided advan-
tages accrue after its application." It may likewise be employed
to effect abortion, when the indications show the necessity for, or
justify the expulsion of the ovum.

7. The fresh Inner Bark of the Root of the Cotton plant is stated
by Dr. Bouchelle to have a particular affinity for the sexual organs,
modifying their functions in a remarkable manner; that it not only
possesses oxytocic properties, invigorating feeble contractions of
the uterine fibers, but that it originates expulsive contraction at any
period of gestation, and will induce immediate abortion when taken
in the proper quantity, and without any detriment to the health of
the female. He states, also, that it was habitually resorted to by
slaves in the South as an ecbolic for the criminal purpose of induc-
ing abortion, a fact which I have in past years had named to me a
number of times by Southern practitioners. Dr. B. infers, from
its influence on females, that the use of it destroys the generative
capacity, rendering the person sterile, without impairing the health ;
should this eventually prove to be the case, the bark of cotton root
will become a most important article of our Materia Medica, a
boon to physicians, and likewise to females with deformed pelves ;
and it is to be desired that its value in this matter will be thoroughly
investigated. It is used in strong decoction as an ecbolic or oxy-
tocic, of which four fluidounces may be taken every twenty or
thirty minutes until the desired result is obtained.

8. Prof. Giordano, of Turin, advises the application of solid
nitrate of silver to the cervix, as being of easy execution, prompt
and complete in its results, and followed by no ill consequences.
Having introduced the caustic within the cervix, he imparts to it
repeated, but slight, rotatory movements, so that most of the sur-
face may undergo the process of cauterization. Caoutchouc bags
or pessaries introduced within the cervix, and then inflated have
likewise been frequently employed with success.

After uterine contractions have been fully established by the
adoption of either of the above measures, to induce premature
delivery, the labor will proceed in the same manner as at full term,
and its management, as well as that of the placenta, will also be

INDUCTION OF PREMATURE LABOR.

613

the same as recommended at that period. As a prematurely
delivered child is more feeble than one fully developed, some care
will be required in its management; it should be kept warm,
allowing it, however, a free use of its limbs, and a wet nurse should
always be provided for it, who should be directed to adopt a system
of regularity in applying it to the breast, at no time allowing it an
excess of aliment.

A solution of half a grain, or a grain of sulphate of iron in two
fluidrachms of water, carefully injected into the pregnant uterus,
is much employed among abortionists to effect their object.
Another plan, which is considerably used, is to pass up a Simpson's
sound into the uterus, feel around with it for the placenta and
detach a small portion of its periphery, enough to cause a little
blood to flow; in twelve or twenty-four hours, the uterus contracts
and sooner or later expels its contents. It is hardly worth while
to state to the medical student, the dangers that are apt to follow
abortions thus effected, nor the legal liabilities to which the oper-
ators are subject.

\

PART V .

DISEASES INCIDENT TO PUERPERAL FEMALES,

AND INFANTS.

CHAPTER XLVII.

PUERPERAL FEVER PERITONITIS INFLAMMATION OF THE UTERINE APPENDAGES — METRI-
TIS UTERINE PHLEBITIS INFLAMMATION OF THE UTERINE ABSORBENTS TREATMENT

OF PUERPERAL FEVER.

One of the most dangerous forms of disease to which the puer-
peral woman is liable, is that commonly known as PUERPERAL
or CHILD-BED FEVER— concerning which there have been,
from time to time, various and discordant opinions expressed by
medical writers, as well as sundry modes of treatment recom-
mended, each being based upon the particular theory supported by
its originator. This clashing of views has, perhaps, originated
from the fact, that the malady termed puerperal fever, has
included several phenomena which have not been uniform, and
which have yielded to the most opposite plans of treatment — and,
each writer being entirely governed in his opinions upon the sub-
ject, by the particular symptoms and circumstances presented to
his individual notice, has, probably, been induced to infer that,
while others have mistaken the true nature of the disease, he has
correctly ascertained it, together with the best treatment for its
cure. At the present day it is generally acknowledged that the
malady varies in its pathological characteristics.

PUERPERAL FEVER.

615

Puerperal fever, has, heretofore, proved very fatal in its result,
destroying a large majority of those who have been attacked by
it, and has undoubtedly occasioned more than two-thirds of the
deaths which have occurred among females at the puerperal period.
It is more malignant in hospital, than in private practice, which
may be owing to the congregation of too many patients in a ward,
as well as to a neglect of proper ventilation, and thorough and
constant cleanliness of the various lying-in apartments. The
poorer classes of society, from their indigent mode of living, and
the illy-ventilated, unclean, and damp rooms, which their circum-
stances compel them to occupy, are more subject to the disease
than those who can obtain the proper necessaries and conditions
for health, and it also proves much more fatal among them.

The attack commonly occurs within two or three days after
delivery, but it has been met with previous to labor, and also at
the third or fourth week succeeding it ; and when it does occur, it
usually runs its course speedily.

CAUSES. — Puerperal fever most generally prevails as an epi-
demic, and it is not uncommon, at epidemical seasons, to observe
that nearly every puerperal woman within the abnormal district,
suffers from an attack. This may be owing to the great suscepti-
bility which the parts must have to diseased action, arising from
the nervous shock, the sudden evacuation of the abdominal cavity,
the powerful contractions of the uterus and abdominal muscles,
and other circumstances connected with labor; indeed, when we
consider all the phenomena present during the birth of a child, and
more especially in difficult, and instrumental labors, it is rather
a source of astonishment, that the disease is not still more fre-
quently met with. When occurring as an epidemic, it is more
malignant and fatal in its character than when it exists spontane-
ously, and those females more readily fall victims to it, who are
exposed to any of the causes hereafter assigned for its spontaneous
advent.

Independently of an epidemic origin, puerperal fever may be
produced by an exposure to cold, or to dampness ; by an omission
of the bandage ; by the female arising from her bed at too early
a period ; by allowing her improper food, or stimulants, during the
first puerperal week ; by violent emotions of the mind, whether of
a depressing or exciting character; by a retention of portions of
the placenta: and, notwithstanding that venesection is frequently
recommended as a means to overcome the disease, yet we find that

616

AMERICAN ECLECTIC OBSTETRICS.

it frequently follows excessive floodings. I have several times
noticed a disease resembling it to follow a constipated condition of
the bowels, in cases where the attending accoucheur had permitted
the patient to remain without any alvine evacuation for ten or
twelve days. Manual and instrumental labors render the puerperal
female especially obnoxious to this disease. And frequently it is
impossible to assign any satisfactory cause for its origin.

The malady occurs more frequently, and with greater malig-
nancy in cold seasons, and during damp, or moist conditions of the
atmosphere, while in warm and dry seasons it is less common, and
more favorable in its results.

Much has been said about the contagious, or non-contagious
character of puerperal fever ; some of our most eminent medical
men maintaining that it is decidedly contagious, and others,
equally as distinguished, supporting an opposite opinion. It is
a very difficult matter to satisfactorily determine this question,
because the extension of the disease, during its epidemic existence,
may be safely attributed to its epidemic nature; while, on the
other hand, instances have occurred which so strongly manifested
a contagion, or an extension without epidemic influences, that, to
say the least, it would be exceedingly impolitic to make any posi-
tive declarations relative thereto. Perhaps, there may be some
forms of this disease, as for instance the erysipelatous, which may
be communicable, even when it occurs spontaneously; while other
spontaneous forms are, probably, never contagious; the subject
requires still further investigation.

I can not, however, divest myself of the opinion, that it is a con-
tagious disease, especially the typhoid and erysipelatous varieties;
for, notwithstanding the statements and reasonings of those emi-
nent gentlemen who favor the side of non-contagion, I have wit-
nessed so many instances in which its existence could be accounted
for in no other way than by contagion, that other explanations
than those I have met with will be required to change my views
on this subject. In the present unsettled condition of this question,
whatever may be our opinions, I believe with Dr. K. Lee, uthat it
is our duty to act in all cases as if the contagious nature of the dis-
ease had been completely demonstrated." The accoucheur who is
attending a case of puerperal fever, should, for a season, avoid
waiting upon any parturient females; he should likewise forbid
the presence of pregnant women within the apartment of his
patient, as instances have occurred, where the only assignable cause

4

PUERPERAL FEVER.

617

for the attack, was the presence of the female, during pregnancy,
in the room of a child-bed-fever patient. It is likewise stated by
some authors, that a similar exposure of the non-pregnant female,
during the catamenial period, has occasiftned fever of a somewhat
similar character.

The several varieties of puerperal fever, are classified according
to the pathological conditions which are present, and may be
described as follows :

1. Peritonitis, or inflammation of the uterine peritoneum, and
peritoneal sac.

2. Inflammation of the uterine appendages, as the ovaries, Fallo-
pian tubes, and ligaments.

3. Metritis, or inflammation of the mucous, and muscular, or
proper tissue of the uterus.

4. Uterine phlebitis, or inflammation and suppuration of the veins
of the uterine organs.

5. Inflammation of the uterine absorbents.

I. PERITONITIS, of the lying-in female, is usually ushered in
with rigors, more or less severe in their character, and which are
preceded, accompanied, or followed by uterine tenderness, or pain.
The rigors may be very slight, scarcely perceived by the patient,
or they may be very violent, resembling an attack of intermittent
fever, with coldness of the extremities. The pain, however slight
it may have been at first, gradually increases in severity, at the
game time extending itself over the abdomen. In the early part
of the disease it may be mistaken for after-pains, but may be
determined from them, by making pressure, during the intervals,
over the iliac and hypogastric regions — if no pain or soreness is
produced, there is no peritonitis. But if the pain has obstinately
persisted for several days, with symptoms of constitutional disturb-
ance, there will be strong reasons for suspecting a lurking inflam-
mation. Commonly, when pressure is made over the regions just
named, the patient being attacked with peritonitis, will complain of
pain. Cases, however, are recorded in which the most severe form
of puerperal peritonitis existed, without any tenderness or pain in
the abdominal region.

The rigors pass away after a short period, and are followed by
febrile symptoms, as flushed face, great heat of the surface, thirst,
sometimes nausea and vomiting, short and hurried respiration, and
an intense pain across the forehead. The pulse, during the rigor,
40

618

AMERICAN ECLECTIC OBSTETRICS.

is usually full, strong, and accelerated, beating from. 110 to 140 in
a minute; bat as the disease progresses, it loses its hardness and
volume, and becomes more frequent, small, and wiry, beating from
130 to 160 and upward in a minute ; aud in all cases when the pulse
of a puerperal female remains persistently above 100 beats in a
minute, it is good evidence of the existence of some abnormal
action. The tongue is usually covered with a thin, moist, white
or cream-like film, but red at the edges; and sometimes the whitish
film is absent, and the whole surface of the organ is red. As the
disease progresses, the coating becomes yellowish or brown, and
occasionally there will be a dryness of the tongue, with a brownish
coat from the commencement. The lochial discharge may be com-
pletely suppressed, or only lessened in quantity, and occasionally
it continues to flow as usual. The secretion of milk is most gen-
erally suspended, and the mammae become flaccid. The urine is
scanty, turbid, or high-colored, with more or less difficulty in void-
ing it. Obstinate constipation is generally present in the early part
of the disease. The countenance of the patient is peculiar, after
the disease has formed itself completely, presenting a ghastly,
pallid, anxious, and suffering appearance, with a livid hue under
the eyes. Sometimes a crimson patch will be observed on one or
both cheeks, which is an unfavorable symptom.

At the onset of the disease the abdomen is generally soft and
flaccid, but becomes swollen and tympanitic as the disease advances.
From the commencement of the attack, any motion of the lower
limbs will occasion more or less pain: when this is severe, the
patient usually lies upon her back, with the knees drawn up to the
abdomen; which posture she retains on account of the pain caused
by extending them. The pain eventually becomes so intense that
she is unable to bear the least pressure upon the abdomen; the
bandage will have to be loosened or removed altogether, and fre-
quently the hands will be employed in holding up the bedclothes
to remove their weight from the suffering parts. The least motion,
as turning on one side, coughing, etc., occasions great suffering, in
consequence of which she lies remarkably still, manifesting her
distress and uneasiness by screams and moans, by throwing her
arms about, and occasionally turning her head from side to side.
With the tympanitic condition of the abdomen the pain will
become more aggravated, or it may entirely subside. The patient
will frequently be indifferent to the welfare of her infant, even
refusing to give it suck.

PERITONITIS.

619

As the inflammation extends throughout the abdominal organs
the tympanitic condition of the abdomen increases; the vomiting,
which was at first mucous or bilious matter, becomes green, brown,
or blackish, like coffee-grounds ; the evacuations become dark and
fetid, or a diarrhea may be present, which is an unfavorable symp-
tom; the skin becomes cold and clammy; the pain ceases, an
evidence that effusion has taken place; if the diaphragmatic peri-
toneum has been involved in the inflammation, hiccough takes
place. Generally, the female retains her senses until near the end
of the disease, when low, muttering delirium ensues, with carpho-
logia, or picking at the bedclothes; the lips, hands, and feet become
purple ; the pulse gradually diminishes, ceasing at the wrist, elbows,
and axillae, when death speedily closes the scene.

All the symptoms named will not generally be found in any one
case; perhaps the most uniform among them is the frequent pulse.
This, together with rigors, pains, vomiting, and tympanitis, are
more commonly observed.

DIAGNOSIS. — It is not a very easy matter to determine
between the varieties of uterine inflammation, in puerperal fever,
as the symptoms, in a great measure, bear some resemblance ; nor,
in a practical point of view, is it of much importance, as the treat-
ment in each of them, whether existing singly or combined, will
be nearly the same. Yet it will be proper, notwithstanding, to
name some of the distinguishing marks between peritonitis and
other disorders, for which it may sometimes be mistaken.

It may be determined from hysteralgia, or after-pains, by observ
ing that in these there is but little tenderness on pressure during
the absence of the pains; that the uteras perceptibly contracts and
hardens when they are present, which is not the case with tl^e peri-
toniticpain; and that the pains diminish from day to day, while
that of peritonitis rapidly augments. The pulse is frequent, in
puerperal fever, and but seldom so in hysteralgia; and when this
is the case, unlike the pulse of peritonitis, it soon falls to a normal
condition. In peritonitis, the disturbance to the general system
increases every day, while in hysteralgia it gradually ceases.

Intestinal irritation, from depraved secretions or fecal accumula-
tions, is frequently mistaken for puerperal fever. This difficulty
generally attacks at a later period than peritonitis, and does not
occasion so much constitutional disturbance. The pain in the
abdomen is equally diffused, and does not spread from a focus ; the
uterus is not tender nor enlarged ; the abdomen is soft and puffy,

620

AMERICAN ECLECTIC OBSTETRICS.

not tympanitic, nor does pressure aggravate the pain to any extent,
and the patient can more readily move in bed. In each there may
be chills, heat of skin, headache, rapid pulse, loaded tongue, flatu-
lence, nausea, vomiting, and diarrhea or constipation. Intestinal
irritation is said to be frequently confounded with peritonitis, and
is supposed to be the reported " violent cases of peritonitis in which
the patient dies between the stage of excitement and of effusion,
and no effusion or signs ol inflammation are found."

In metritis or hysteritis, but little pain is produced on pressing
the abdominal parietes until the enlarged uterus is touched, while
in peritonitis, the least degree of pressure on the abdomen causes
severe pain. The other symptoms of metritis are less general than
those of peritonitis.

POST-MORTEM APPEARANCES.— The peritoneum, espe-
cially that portion covering the uterus, is red, vascular, thickened,
and sometimes softened, and is frequently covered with a layer of
lymph, resembling a false membrane, which occasions adhesions
between the omentum and intestines, and sometimes between the
omentum and fundus uteri. The redness will be the more intense,
and the thickening of the peritoneum the greater, in proportion to
the duration of the pain and the severity of the disease. The
omentum frequently exhibits marks of inflammation, being red
and highly vascular ; and this may be found without any evidences
of inflammation of the peritoneum. The serous coverings of
the several organs, in the cavity of the abdomen, may exhibit evi-
dences of inflammatory action. A turbid, whey-colored, or red
serum, with purulent or albuminous shreds floating in it, or a yel-
lowish lymph, are effused, in greater or smaller quantity, into the
peritoneal cavity, and sometimes blood will be found, alone, or
mixed with the serous fluid. Pus is frequently found deposited
behind and around the uterus, beneath its peritoneal covering,
and at those points where the inflammation has appeared to be
the most active.

II. INFLAMMATION OF THE UTERINE APPENDAGES,
may exist in conjunction with inflammation of the peritoneal cov-
ering of the uterus, or it may occur entirely independent of it :
more frequently, however, they are met with together, and when
this happens, the symptoms common to peritonitis will be present,
with the addition of those which belong to inflammation of the
appendages.

METRITIS.

621

When the serous membrane and proper tissue of the ligaments,
Fallopian tubes, and ovaries are attacked with inflammation, while
the peritoneal sac is but slightly affected, or not at all, the pain
will be located principally in one of the iliac fossre, extending from
thence to the groins, anus, and down the thighs. On making
pressure, the pain will be experienced in the lateral portions of the
hypogastrium, and will be less intense than in general peritonitis.
An examination per vaginum will find the upper part of this canal
hot and painful. The constitutional symptoms are similar to those
of peritonitis, as rigors, hot skin, thirst, headache, frequent pulse,
etc. When the attack is severe, prostration takes place rapidly,
and the disease may speedily prove fatal. Or, it may terminate in
resolution, without injury to the organs; with obliteration of one
or both of the Fallopian tubes; or with adhesions between the
tubes and parts in proximity, or of portions of serous membrane,
and which may subsequently prove injurious.

Or, it may terminate in suppuration, matter being formed in the
ligament or ovaries, and escaping into the peritoneal sac ; through
the vaginal or rectal walls; or, through the walls of the abdomen
in the neighborhood of Poupart's ligament.

POST-MORTEM APPEARANCES.— The surface of the Fal-
lopian tubes, ovaries, and broad ligaments, are red and vascular,
and are imbedded to a greater or less extent in pus or lymph. The
fimbriated extremities of the tubes are of a deep-red color, and fre-
quently softened, and diffused or circumscribed deposits of pus may
be observed beneath their coverings, and in their cavities. Effu-
sions of pus or serum may likewise be found between the folds of
the broad ligaments, and small masses of pus will be met with, dis-
persed throughout the enlarged ovaries ; or these organs may be
converted into a cyst holding pus, which escapes through ulcerated
openings. One or both of the ovaries may exhibit evidences of in-
flammatory action, their peritoneal coat being red, vascular, and
imbedded in lymph. They may be greatly enlarged, swollen, red,
and pulpy, or there may be no apparent change in their paren-
chymatous structure. On dividing the ovaries, a great augmenta-
tion of vascularity will be seen, with a softening, or complete disor-
ganization of its proper tissue. Occasionally, there will be an effu-
sion of blood into the Graafian vesicles, destroying their texture.

III. METRITIS, HYSTERITIS, or INFLAMMATION OF
THE UTERUS, commences most commonly on the third or fourth

622

AMERICAN ECLECTIC OBSTETRICS.

day after delivery, with rigors, followed by a hot and dry skin,
thirst, headache, accelerated pulse, dry and furrred tongue, with
pain and tenderness in the uterine region, though pressure upon the
abdomen occasions no pain until the hard and enlarged uterus is
reached. The abdomen, at first soft, becomes tympanitic, and if
the proper remedies are withheld the inflammation may extend to
the peritoneum, when the pain will spread over the abdomen, being
attended with the symptoms peculiar to peritonitis. The lochia!
discharge may be diminished or suspended, and may remain
unchanged, or become of a dark color, and very fetid. The secre-
tion of milk is generally defective ; the urine is scanty, occasioning
much pain when voided. A vaginal examination will find the
os uteri very hot and tender.

In the more severe attacks, the above symptoms will exist in an
augmented degree, with a pale countenance expressive of pain and
great anxiety. The skin frequently becomes cold assuming a sal-
low or bluish tinge. The pulse becomes rapid and feeble ; the
respiration hurried and distressing, with excessive prostration of
strength. The pulse is more feeble, and the patient becomes more
speedily prostrated, than in peritonitis.

If the disease progresses without amelioration, the tongue
becomes coated with a dark or brown fur ; the teeth and lips cov-
ered with sordes ; the extremities become cold, with cold and
clammy perspiration ; vomiting is most usually present and also
an obstinate diarrhea, the strength fails rapidly, with coma, or low
muttering delirium, subsultus tendinum, and death. Metritis may
terminate in resolution, abscess, softening, or gangrene ; the milder
varieties in the first-named, and the more severe in one of the
latter.

POST-MORTEM APPEARANCES.— The uterus will be found
enlarged, and its substance soft and flabby, presenting a dark pur-
ple, grayish, or yellowish pulp, sometimes of a very offensive odor,
and which may exist in patches, or occupy a large tract of the
organ. The softening generally proceeds from the inner uterine
surface, and extends through, involving the peritoneal covering.
Frequently there will be extensive disorganization of the muscular
tissue of the uterus, without any change in the character of the
peritoneal coat. All parts of the uterus may be attacked by inflam-
mation and softening, and, frequently, that portion to which the
placenta was attached is alone found to be disorganized. Coagu-

UTERINE PHLEBITIS.

623

lable lymph forming false membranes, and mixed with blood, and
lochia, are also found on the inner mucous membrane ; and in a
few instances, instead of a complete disorganization of the muscu-
lar tissue of the uterus, small abscesses containing pus have been
found in this tissue.

The peritoneum, covering the inflamed part of the muscular
coat of the uterus, very often presents evidences of inflammatory
action ; it may be red, yellow, or livid, having a disposition of
lymph on its surface, or without this, but so softened in its texture
as to be readily torn.

IV. UTERIKE PHLEBITIS, or inflammation of the veins of
the uterus, may be produced by any of the causes that occasion the
other forms of puerperal fever. The symptoms are similar to the
preceding attacks, as rigors succeeded by hot skin, thirst, accele-
rated pulse, head-ache, etc., together with pain in the uterine region,
which is much increased on pressure, and a suppression of both the
lochial discharge and the secretion of milk. Frequently a con-
fusion of mind, or incoherency will be observed.

The disease progresses very rapidly, the symptoms augmenting
in intensity ; rigors will frequently be present, especially during
the early part of the attack, succeeded by an increased heat of the
surface, the tongue becomes dry and brown, with insatiable thirst,
rapid, full pulse, hurried respiration, vomitings of a greenish fluid,
tremors of the muscles of the face and extremities, excessive
drowsiness, or violent delirium. The body becomes of a deep
sallow color, and sometimes petechias, or vesicular eruptions will
be seen on various parts of it. The abdomen is frequently swol-
len and tympanitic, and the tenderness in the uterine region is
increased ; occasionally, no pain is present.

Death may take place during the acute stage, or the patient may
recover from the primary attack and have her life shortened by
secondary affections of the other parts, as for instance: congestion
of the vessels of the brain, and deposition of lymph or serum into
the ventricles; arachnitis; softening of portions of the brain; or
deposit of pus into the cerebral substance. Congestion of the
lungs, or disorganization of their substance; pleuritis; effusions
of serum or blood; gangrene, etc. Hypertrophy of the heart with
softening, and occasionally depositions of lymph and serum in the
pericardium. Inflammation and softening of the mucous coat of
the stomach; effusions of reddish serum between its mucous and

624

AMERICAN ECLECTIC OBSTETRICS.

muscular tissues. Softening and perforation of portions of the
intestines. Congestion, softening, or abscess of the liver, or of the
spleen. Inflammation of the kidneys, with depositions of pus,
softening, etc. Inflammation of the conjunctiva, with effusion of
lymph in the anterior chamber, destroying sight. Inflammation
of the joints, with abscess, and infiltration of a sero-sanguineous
fluid into the muscles or cellular substance of the limbs, present-
ing the appearance of erysipelas. Sometimes abscesses form
discharging enormous quantities of pus, rapidly prostrating the
patient.

DIAGNOSIS.— This is very diflicult to distinguish from the
preceding varieties, especially during its early stage. The pain
and tenderness is more confined to one spot than in peritonitis,
and when the disease has continued for some time, the secondary
affections will manifest themselves.

POST-MORTEM APPEARANCES. — The uterine veins are
found changed, having their coats thickened, and their canals fre-
quently so closely contracted as to be almost, if not quite imper-
vious; and their lining membrane will be pale and covered with
lymph or pus, frequently it will be of a bright scarlet color.
Similar conditions will be found when distant veins are involved,
with a hardening of the surrounding cellular tissue, which con-
tains depositions of pus. Most commonly the inflammation is
confined to the veins of one side only, and which is the side cor-
responding with that of the placental attachment. Occasionally
the veins will be plugged up with firm coagula, or other abnormal
substances. Beside the uterine veins, the spermatic are more fre-
quently affected — and the disease may extend rapidly to the hypo-
gastric veins. The renal veins are generally involved, with a soft
and vascular condition of the substance of the kidney.

V. INFLAMMATION OF THE UTERINE ABSORBENTS,
or Lymphatics, presents all the symptoms common to uterine
phlebitis, from which it is almost impossible to distinguish it. It
is likewise followed by secondary affections similar to that disease.

POST-MORTEM APPEARANCES.— Pus is found at different
points of the lymphatics, generally at nearly regular intervals,
presenting a beaded appearance.

PROGNOSIS. — These several varieties of puerperal fever may
exist singly or combined, more frequently the latter ; and as their

TREATMENT OF PUERPERAL FEVER.

625

symptoms so closely resemble each other, when combined it will
be a difficult matter to positively distinguish between them, yet in
a practical view, as before related, this is of minor importance, the
treatment being the same.

The prognosis is always unfavorable, and especially when the
disease occurs epidemically. The most unfavorable symptoms
are suppression of the lochia, tympanitis, delirium, vomiting of
greenish, or " coffee-ground " substances ; very high pulse, or
thready and fluttering; hiccough; diminished pain on pressure,
with increased ability to move the legs, and a frequent, feeble
pulse, evidencing that the inflammation has terminated in effu-
sion; cold, clammy skin; diarrhea, or involuntary stools; and
dilated pupils. The most fatal period is during the third or fourth
day.

But if, with an ability of the patient to move herself in bed, we
find the pulse to lessen in frequency, the skin to become cooler
and softer, the thirst gradually diminishing, the tongue cleaning,
the bowels being more easily acted upon, the clearness of the
skin returning, and the patient more able to make a deep inspira-
tion, and to obtain refreshing sleep, we may augur favorably.
The ability tg change position without much pain, is frequently
one of the first symptoms of improvement. Yet, even with all
these favorable indications, we must not cease in our close atten-
tions to the patient, for it has happened, that when there was
every indication of a favorable result, and physicians and friends
were congratulating each other relative thereto, that the symptoms
have returned with increased severity, and the attack has termi-
nated fatally.

TREATMENT. — It is seldom that puerperal fever has exactly
the same features, each epidemic presenting symptoms peculiar to
itself. If we admit only the five varieties of the disease, as
described above, and which may occur separately, or in various
combinations with each other, we have then, twenty-six different
modes of manifestation, in which there will be a great diversity ot
symptoms, in number, character, and severity. But, when, as is
frequently the case, it prevails simultaneously with erysipelas, we
may then have an additional number of twenty-six, giving to us
fifty-two different features which the disease may present; and,
probably, this fact may lead us to suspect the reason why writers
have given such varied descriptions of it, as having occurred under
their respective observations.

626

AMERICAN ECLECTIC OBSTETRICS.

However formidable a disease may at first appear, which is
capable of presenting so great a number of differences in its
features, yet, for practical purposes, they may be reduced to two
conditions, viz. : that in which the inflammatory symptoms predom-
inate, and that in which the typhoid symptoms prevail. And the
treatment must be governed by the presence of one or the other
of these conditions. The most important object is, to overcome
the congestion and inflammation of the parts attacked, and bring
about resolution — for if the disease terminates in effusion, the
woman almost certainly dies.

In the INFLAMMATORY FORM of puerperal fever, when
called at an early stage of the attack, the bowels should be imme-
diately purged by an active cathartic. In this affection, I prefer
the compound powder of Jalap, sixty grains, combined with ten
or fifteen grains of bitartrate of Potassa. Some practitioners
however, administer Podophyllin, Leptandrin, and the bitartrate,
or nitrate of Potassa, but I do not like the action of Podophyllin
in this disease so well as that of the first named cathartic. As it
is very important, in this disease, to keep the bowels regularly
open, the cathartic must be repeated daily, for the first two or
three days, according to the strength of the patient, after which,
the bowels should be kept free, obtaining one or two moderate
evacuations daily by injections or mild laxatives. It will often
happen that the cathartic will not operate until two or three
fluidrachms of compound tincture of Lobelia and Capsicum,
diluted with a warm infusion of Lobelia, have been injected into
the rectum. The evacuations of the bowels and bladder should be
accomplished without subjecting the patient to the distress and
annoyance of getting up in the bed, or out of it, either by using a
bed-pan, or some old cloths. Indeed, it is much better for her to
keep in the recumbent posture, and without elevating the head
and shoulders by pillows.

It will not be necessary to wait for the catharsis, but endeavor
to get the patient as soon as possible under the influence of the
tincture of Gelseminum, which may be given in fluidrachm doses,
and repeated every hour. If much pain be present, the tincture
of Aconite may be added, from three to five or even ten drops, to
each dose of Gelseminum.

As soon as the cathartic has accomplished its effect, and the
more severe inflammatory symptoms have subsided, the compound
tincture of Virginia Snakeroot should be substituted for the Gel-

TREATMENT OF PUERPERAL FEVEB.

627

Beminura, and may be given in fluidrachm doses every hour or
two, until copious perspiration is produced; it is best given in a
warm infusion of some simple herb, as pleurisy root, catnip, tansy
or balm. Previous to the administration of this, however, the
surface of the body should be bathed with a warm alkaline solu-
tion, drying it with considerable friction, and this should be con-
tinued from time to time during the persistence of the inflamma-
tory symptoms. Diaphoresis once produced, it must be kept up
during the acute stage, occasionally exhibiting the Gelseminum
when the inflammatory symptoms increase in severity.

Equal parts of the tincture of Digitalis and Stramonium, given
in doses of ten or fifteen drops, every hour or two, have frequently
been of advantage in this disease, particularly when the attack
was mild.

Fomentations applied over the abdomen, as hot as can be borne,
will be found a powerful means for relieving the pain and soreness
in that region ; they may be made of hops and tansjr, or hops and
poppy heads, or either of these with chamomile flowers, and they
should be renewed frequently, not permitting them to remain on
when cool, and the patient should not be made uncomfortable by
applying them so wet as to dampen the bed upon which she lies.
For a fomentation to the bowels I know of no agent equal to the
leaves of Stramonium, which are now being used in various
inflammatory affections, by some of my colleagues, upon my
recommendation, and with much success; I have used these when
fresh, by bruising and warming them previous to their application,
or, by steeping the dried leaves in boiling water, and frequently
changing them upon the abdomen. I have persisted in the
appliance of this remedy even after it has caused double vision and
other symptoms of its peculiar narcotic influence upon the system,
and invariably with benefit. It not only lessens pain, but actually
assists in reducing the inflammatory action. When its effects
upon the system are no longer desirable, one of the previously
named fomentations may be substituted. The fomentations will
prove beneficial only during the acute stage, and must be dispensed
with when prostration ensues, or when the inflammation has been
overcome. The addition of oil of Turpentine to them, when
tympanitis is present, has been found useful.

For a common drink the patient may take an infusion of Peach-
leaves and Hair-cap moss, which will occasion diuresis, and thus
aid in lessening the severity of the attack. Or an infusion of

628

AMERICAN ECLECTIC OBSTETRICS.

Peach-leaves and Marsh-mallow root — or, of Horsemint (monarda
punctata), and May-weed (anthemis cotula), each, equal parts.
Either of these may be drank freely, especially in the early part of
the attack. A free action of the kidneys is alwaj^s desirable in
this malady, and should be kept up as much as possible. An
infusion of equal parts of Cleavers, Maidenhair, and Elder-flowers
will frequently prove highly beneficial. In the latter part of the
disease, when the tongue becomes coated dark, brown, or yellow,
acidulous draughts are indicated, as lemonade, tamarind-water,
orange-juice, vinegar, and even tart cider, when there is prostra-
tion. If the patient during the early days of the fever desires ice,
or iced water, they should not be withheld.

When the pain is very severe, and the inflammatory action
intense, in addition to the above-named measures, counter-irrita-
tion will often be very useful ; mustard may be applied along the
whole course of the spinal column, and to the legs, and inside of
the thighs. Some practitioners recommend the application of cups
over the lumbo-sacral region, and even leeches over the abdomen ;
there may be cases in which some transient benefit will be derived
from these, but I have never yet had occasion to employ them —
still, I should not hesitate to do so, were it necessary. But gen-
eral venesection, which is so almost universally advised by writers,
who place their greatest reliance upon it, I am decidedly opposed
to, and am induced, from the results of observation, to believe
that, at least as frequently as the disease itself, it occasions fatal
results. For a full explanation of inflammation, and the influ-
ences of general bleedings, I refer the student to Prof. I. G- Jones'
excellent work, entitled " The American Practice of Medicine,"
vol. I, pages 248 to 321.

After the more severe symptoms have been subdued, many
practitioners discontinue the exhibition of the former internal
measures, substituting for them the compound powder of Ipecacu-
anha and Opium, to be given in appropriate doses, and at intervals
of two or three hours. Others prefer the compound powder of
Quinia. These may be used with advantage, the latter especially
where typhoid symptoms are present.

I would observe that, in many instances, I have found the tinc-
ture of Gelseminum, either alone, or in combination with the tinc-
ture of Aconite, sufficient to resolve the disease, without the aid of
the compound tincture of Virginia Snakeroot ; though when the

TREATMENT OF PUERPERAL FEVER.

629

attack is very severe, I have always found it more advantageous to
cause free diaphoresis.

The vagina should be frequently cleansed by injections of tepid
water, or, an infusion of Golden Seal and Wild Indigo root ; or
of Golden Seal and Lobelia. Sometimes, an advantage will be
gained by carrying the injection within the uterine cavity: but
much care will be required in doing this, not to pass the fluid too
forcibly within it, nor in too large a quantity at a time; say from
two to four fluidrachms at a time, and repeated at intervals of four
or five hours. Sometimes, benefit will follow injections of warm
water into the uterus ; from half a pint to a pint may be used at a
time, and may be repeated every three, four, or five hours. These
injections should always be given by the medical attendant — never
by the nurse ; they cleanse the organ from all abnormal and putre-
fied matters, lessen the sufferings of the patient, and aid materially
in restoring the parts to a healthy condition.

In addition to the external application of Oil of Turpentine for
the tympanitic condition of the abdomen, it "will frequently become
necessary to administer internal means; a mixture of equal parts
of Castor Oil and Oil of Turpentine, may be given in fluidounce
doses, and repeated every two or three hours, until catharsis is
induced. And when this is employed, other cathartics must be
omitted. Sometimes, Paregoric elixir may be advantageously
added to the dose. Or, a combination of equal parts of Oil of Tur-
pentine and Paregoric elixir, may be given in small and repeated
doses, while other cathartics are being employed instead of Castor
Oil. I have met with decided benefit from the use of a saturated
tincture of Prickly-Ash berries, as an injection, and administered
internally. As an injection, it may be employed in half fluidounce,
or fluidounce doses, very slightly diluted with water, and repeated
every half-hour or hour. When there is much pain, half a fluidrachm
of Laudanum maybe added to each injection. In some instauces,
I have beneficially combined it with Oil of Turpentine, with the
compound tincture of Lobelia and Capsicum, and with these last-
named two preparations together. Internally, it may be given alone
in fluidrachm doses, or, combined with Oil of Turpentine and Par-
egoric elixir, equal parts of each, of which from half a fluidrachm
to a fluidrachm, in some sweetened water, may be repeated every
hour or two. The tincture of Prickly-Ash bark will not exert
the same influence upon tympanitis, as that of the berries, which
appears to have almost a specific influence, and may be used per

630

AMERICAN ECLECTIC OBSTETRICS.

rectum at any period of the disease when tympanitis is present. Its
use internally, or by month, must not be commenced until the
higher inflammatory action has become somewhat lessened.

Vomiting is frequently very obstinate, resisting all measures for
a length of time. Generally, the Gelseminum alone, or combined
with some opiate, will check it. Or, some aromatics may be used,
as Peppermint-water, Anise-water, Spearmint-water, etc., with
Laudanum. * Frequently, a Mustard poultice to the epigastric region
will be of service in lessening the vomiting. Sometimes, efferves-
cent acidulous draughts will be useful, as Soda or Seidlitz water,
with Lemonjuice, and a few drops of Laudanum. And when these
do not cause it to yield, it will diminish with the abatement of the
inflammation.

In the TYPHOID FORM of puerperal fever, the course of man-
agement for the first day or two, during the more active stage of
the disease, may be the same as in the preceding form, but after-
ward, it will require considerable change; and the means, which I
am about to advise for the purpose of combating the typhoid symp-
toms, may also be employed when symptoms of a similar character
are present in the depressing stage following the inflammatory.

As soon as it becomes evident that the disease is assuming the
typhoid form, the more active and depletory measures must be dis-
pensed with. Instead of creating active diaphoresis, the surface
must be kept slightly moist, and sulphate of Quinia, in doses of
from three to five grains, with an equal quantity of the compound
powder of Ipecacuanha and Opium, may be given for a dose, and
repeated every two, three, or four hours, as may be required. Or,
the compound powder of Quinia may be substituted for it. The
surface should be occasionally bathed with an alkaline bath, ren-
dered somewhat stimulating by the addition of spirits or alcohol.
For the purpose of keeping the bowels free, and procuring one, but
not over two, moderate alvine discharges, daily, Podophyllin and
Leptandrin, in sufficient quantity to produce this effect, may be
added to each dose of the above Quinia powders. But, as a general
rule, I prefer the crude root of the Leptandra Virginica, itself, as
being much more efficacious and benefical, than either the Podo-
phyllin or the Leptandrin. A tablespoonful of a strong infusion
of the root, may be given every hour or two through the day, or
sufficiently often to bring about the desired result. And this should
be continued throughout the whole course of the disease.

TREATMENT OF TYPHOID PUERPERAL FEVER.

631

The pain and tympanitic condition of the abdomen must be
treated as already described.

As soon as the patient desires acidulous draughts, permit them to
be taken, not forgetting that when the tongue is furred dark or
yellow, good tart cider is not only refreshing, but is powerfully
sanative in its effects.

When the prostration is excessive, sherry, or sparkling Catawba
-."ine, porter, good French brandy, etc., may be given to support
the system until reaction comes on : if there are putrid symptoms
present, equal parts of yeast aud sweet oil may be given in table-
spoonful doses, and repeated every hour; or diluted pyroligneous
acid may be exhibited; or an infusion of two parts of Leptandra
root and one of wild Indigo root may be administered in table-
spoonful doses every hour or two. Aud I would here refer the
student to the treatment for putrescency, and other symptoms
accompanying absorption of the decomposed placenta, on page 509,
and which, to a great extent, will be applicable in this form of puer-
peral fever.

An equilibrium of the temperature of the surface must be main-
tained by cooling lotions to the head, and warmth and stimulants
to the extremities. In some cases, where the prostration was exces-
sive, I have applied cold to the head, with sinapisms around the
legs from the hips down to the feet, and around these placed heated
rocks, or bottles of heated water, and with marked advantage.
It may frequently become necessary to cut the hair close, when
there is much disturbance of the brain, before applying the cooling
lotions.

When diarrhea is present, I know of no fetter agent than the
tincture of Chloride of Iron, either with or without some prepar-
ation of Opium. It may be given in doses of ten or twenty drops,
repeated every hour, in a sufficient quantity of water, and at the
same time an injection, after each diarrheal evacuation, should be
given, composed of Tannic Acid ten grains, compound tincture of
Virginia Snakeroot one fluidrachm, Water one fluidounce, mix.
This should be retained by the patient as long as possible. The
tincture of Chloride of Iron has a powerful and beneficial influ-
ence on the capillary vessels, and it will not only be found valuable
in the diarrhea attending this malady, but also in those cases com-
plicated with erysipelas. Whenever I have good reasons for know-
ing that erysipelas is connected with the puerperal fever, as soon as
the more active symptoms have been somewhat diminished, I

632

AMERICAN ECLECTIC OBSTETRICS.

administer fifteen or twenty drops of this tincture in a proper
amount of water, repeating it every hour, until the symptoms have
yielded, and in no instance has its exhibition been otherwise than
beneficial. In many instances I have, from the commencement of
the attack, administered the tincture of Aconite, and the tincture
of Chloride of Iron, alternately, every half hour or hour, and with
the most happy results. But should I meet with a patient in whom
it increased the symptoms, of course, I should cease or suspend its
use. May not the erysipelatous and typhoid characters of this
affection frequently be owing to absorption of putrid matter, as
decomposition of coagula within the uterine cavity, or of remain-
ing pieces of placenta or membranes ?

In the early stage of puerperal fever the diet must be light and
cooling, but more nourishing in the latter stages, as gruel, panada,
toast, bread-water, rice-water, barley-water, apple-sauce, prune-
water, tamarind-water, etc. And after the danger has passed, the
patient remaining much debilitated, chicken-broth, beef-tea, veal-
tea, etc., with or without sherry wine, as the case may require, may
be allowed, increasing the nutritious character of the diet gradu-
ally, as she continues to improve.

It would be impossible to lay down specific rules for the guidance
of the practitioner in treating the various forms under which puer-
peral fever may individually appear. The above general principles
of treatment will be found the most successful, although it may
require to be modified, or pursued more or less energetically,
according to the phenomena which are present. Other means have
been advised, some of which are undoubtedly valuable, yet I have
considered it the better course to name only those principles of
treatment, in this malady, which I have found successful in my
own experience. And in closing upon this subject, I would
remind the student that not only must he carefully and attentively
watch his patients who labor under childbed fever, but he must
also use every means to avoid propagating the disease, the same as
if its contagious nature were satisfactorily demonstrated.

Frequently, the disease may be prevented by an early attention
to the bowels and kidneys — evacuating them by the proper agents,
maintaining a determination to the surface by some diaphoretic
powder, applying a fomentation to the abdomen when the pains
are of a suspicious character, and avoiding exposures to cold, and
damp or moist atmosphere.

Dr. J. F. Henderson, of Indiana, informs me that he has success-

TREATMENT OF TYPHOID PUERPERAL FEVER.

633

fully treated cases of puerperal fever by the following method :
after having evacuated the bowels, and even previous to the action
of the cathartic, he administered a mixture of half a fluidounce of
Copaiba, with ten or fifteen drops of oil of Turpentine, repeating
the dose every four hours. A cloth wet with cold water was kept
to the head, and the patient was permitted to drink freely of
a strong infusion of Tansy. Cloths were applied to the abdomen,
wet with a strong and warm infusion of Hops and Tansy, changing
them frequently. As soon as the bowels were evacuated, a pow-
der composed of Sulphate of Quinia five grains, and compound
powder of Ipecacuanha and Opium six to ten grains, was given,
and this dose was repeated every four hours, until five or six pow-
ders had been administered. The Copaiba and Turpentine was
continued, together with the fomentations, until all pain and ten-
derness had been removed, and free perspiration induced, which
was generally on the second or third day, seldom longer. In every
case the lochia was re-established in two, three, or four days. The
bowels were kept regular by the daily use of Leptandrin.

The most prominent symptoms attending his cases, were — full-
ness and pain in the head and eyes; more or less chillness, and
with some severe rigors, pain in the hips, muscles, and joints, at
first slight but soon becoming severe; quick, tense, and full pulse;
pain and tenderness over the uterine region, the whole abdomen
being morbidly sensitive ; scanty and high-colored urine ; suspen-
sion of the lochia; more or less intense heat of the surface; and,
as the disease progressed, all these symptoms became aggravated;
the conjunctiva and edges of the lids became red and congested ; in
some cases the globe of the eye seemed to be literally swimming
in water ; and the countenance exhibited a peculiar, earnest, plead-
ing, and indescribable expression, that when once seen, it could
not be forgotten nor mistaken for any other condition. In most
of the patients there were slight remissions in the morning, and
in some an entire intermission, but of short duration. Generally,
on the second day the tongue was dry and coated white, and, with
some patients, slight delirium came on at this time. Obstinate
constipation was present in all.
41

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AMERICAN ECLECTIC OBSTETRICS.

CHAPTER XLVIII.

PHLEGMASIA DOLBNS CRUKAL PHLEBITIS TREATMENT OF PHLEGMASIA DOLENS.

PHLEGMASIA DOLENS, is the name applied to a swelling of
one or both legs which occurs soon after delivery, and is accom-
panied with pain and tenderness. The disease has been termed
milk-leg, from a mistaken idea that it was owing to a metastasis of
milk from the breasts to the legs. It has also received several
other names, according to the views of writers, thus, oedema dolens,
oedema lacteum, phlegmasia alba dolens puerperarum, metastasis lactis,
depSt du lait, and crural phlebitis. It may attack primiparae but is
more frequently met with among multipara?.

Although this disease has been known to the profession for
a long time, yet its nature has not been satisfactorily understood,
and, even at this time, there are conflicting opinions regarding it.
Mr. White, of Manchester, in 1784, considered it to be caused by
an obstruction, or some morbid condition of the lymphatic vessels
and glands of the parts attacked. Mr. Trye, in 1792, supposed it
to depend upon a rupture of the lymphatics, as they cross the
pelvic brim. Dr. Terrier attributed it to inflammation of the
absorbents. Dr. Hull, in 1800, considered it to be an inflammatory
disease, producing a sudden effusion of serum and lymph. In 1817,
Dr. Davis made an autopsy, and found evidences of extensive
inflammation of the veins. In 1823, M. Bouillaud, supposed it to
be owing to obstruction of the crural veins, having found these
veins obliterated in several females who had labored under the
disease. In 1829, Dr. Robert Lee succeeded in tracing the inflam-
mation into the uterine branches of the hypogastric veins, and he
gave it the name of Crural Phlebitis.

The most commonly received opinion, at present, and which is
based upon post-mortem appearances, is, that the immediate cause
of phlegmasia dolens, is inflammation with more or less obstruction
of the crural veins, the inflammation, in many instances, extending
from the uterine veins, being seated principally in the cellular and
middle tunics of the veins.

Dr. Mackenzie, from the results of a series of experiments, is ot
the opinion that phlegmasia dolens is owing to a vitiated condition
of the blood, and that the venous inflammation is rather an effect
of the original disease. He states that all the phenomena of the
affection will not be produced by inflammation of the iliac or

PHLEGMASIA DOLENS.

635

femoral veins only; that, during health, a mere local cause, as
inflammation, or an injury, does not produce the extensive venous
obstruction which is found in phlegmasia dolens; that, independ-
ently of inflammation or local injury, an obstruction of the veins
may be produced by an irritation of their lining membrane, and
will be more or less extensive according to the degree of irritation ;
and, that we are rather to look upon a morbid condition of the
blood as the source of this irritation, instead of local injury, inflam-
mation, or disease of the veins.

These views of Dr. Mackenzie appear to be confirmed by the fact,
that, phlegmasia dolens has been known to exist when the uterus
was in a normal state, and also, when the vessels of the thigh man-
ifested no indications of disease, this being confined to the leg only;
again, females suffering under carcinomatous, rheumatic, gouty,
and other diseases, seem to be more liable to the puerperal swelled
leg than others. Tet, it has occurred among those who were
apparently free from any disease up to the time of the attack.
Further investigations will be required before a correct and satis-
factory theory of the malady can be determined. My own view is,
that the disease is primarily an affection of the lymphatics, and that
the venous inflammation is merely a secondary result of the original
malady. Perhaps, there may exist a previous vitiated condition of
the blood, rendering the female more readily susceptible to an attack,
and some cases have occurred under my notice which would favor
such an idea, yet, at present, I am not prepared to make any posi-
tive statements relative thereto. A medical professor has observed
to me, in a communication: "From careful and oft-repeated obser-
vations as to the nature and seat of phlegmasia dolens, I have
become confirmed in the opinion, that it is primarily and essentially
a disease of the lymphatic glands, and subsequently of the lymphatic
vessels of the leg, the inflammation of which extends to the veins,
and to the whole limb.

" This derangement of the lymphatic glands, I believe to be caused
by the pressure of the head of the fetus in passing through the
superior strait, and the reason why the left leg is more frequently
the seat of the disease than the right, is owing to the fact that the
occiput of the child is more generally directed to the left side of the
pelvis. At the lower part of the superior, and the upper part of
the inferior strait, there are many lymphatic glands which are large
enough to be much more prominent than the nerves or veins ; and
they jnust oftentimes become compressed by the occiput of the child

636

AMERICAN ECLECTIC OBSTETRICS.

during its passage. This pressure may cause the glands to become
inflamed and engorged, and the engorgement will cause an oblitera-
tion of their vessels, or, at least, an obstruction to the free flow of
lymph through them, which obstruction will lead to congestion and
inflammation of the inguinal glands, and gradually of the lymphatics
of the entire lower extremity.

" Among the phenomena on which I base this opinion, are,
briefly, the following :

"1. The limb does not become seriously implicated for some lit-
tle time after confinement.

" 2. The lymphatic glands of the groin, and the lymphatic vessels
of the limb are involved for some time before the nerves or veins
appear to be affected ; as evidenced by the locality and character of
the swelling in every case examined ; and also by the exudation of
lymph whenever scarification has been employed.

" 3. The general lymphatic engorgement of the whole limb, and
the cold, white appearance of the part, contra-indicate inflammation
of the veins, or of any other tissue except the lymphatics.

" 4. The invasion of exactly the same form of disease in the arm
of one man after amputation, where the lymphatic glands of the
axilla had become involved, and the lymphatic vessels of the whole
arm had become engorged; and, also, the appearance of two other
cases of phlegmasia in the legs of men where certainly the lymphatics
were first involved. Writers have also observed the same phe-
nomena among males.

" 5. The veins can not, in my opinion, be the primary seat of the
disease, for they do not appear to be affected until after the disease
has existed some days, and, in a few instances, even for weeks, after
the affection of the lymphatics.

"6. The veins, when inflamed, do not present the same phenom-
ena in any other part of the system as are observed in phlegmasia
dolens, as, effusion of lymph, a white, shining surface, and a low
grade of temperature.

"7. The treatment which is found the most successful in cutting
short the disease in its earlier stages, is not such as would be
demanded if the veins or nerves were primarily affected, but, is
such as would be used for inflammation of the lymphatic glands,
and vessels elsewhere."

Phlegmasia dolens, although more commonly met with among
puerperal females, is by no means confined to them; it has been
observed among those whose menstrual discharge has been sud-

PHLEGMASIA DOLENS.

637

denly suspended; or who have had diseases of the uterine organs,
as malignant ulceration of the cervix, polypus, etc. Nor do males
appear to be exempt from it, for it has been known to occur in
them, following dysentery, diarrhea with ulcerated intestines, can-
cer of the rectum, external injuries, amputation of a limb, etc. A
similar affection has likewise been observed to attack the arms in
both males and females, after some injury of the upper part of the
body, or, during some carcinomatous disease of the breast.

Various exciting causes have been named, the most common
among which is cold; it is said also to be excited by pressure upon
the pelvic veins and nerves, uterine disease, suppurative inflamma-
tion of the pubes, injuries, inflammation of the sciatic and obtura-
tor nerves, and sometimes to occur as a sequel of fever.

SYMPTOMS. — This disease most commonly appears between
the tenth and fifteenth day after delivery; though it has been met
with as early as on the fourth day, and again at a later period,
even after the third week. It is generally preceded by pains or
uneasiness in the lower part of the abdomen, with symptoms of
uterine or venous inflammation, and a feeble, depressed, or irrita-
ble condition of the patient; frequently the patient is suddenly
attacked without any premonitory symptoms.

It usually manifests itself with severe rigors, followed by an
increased temperature of the surface, and by a sudden and deep-
seated pain in the groin, or thigh. After a few hours the affected
limb commences swelling, and usually upon its inner and anterior
surface. In the greater number of cases, this swelling is first
observed in the calf, from whence it travels rapidly upward; occa-
sionally, it extends from the thigh downward. Not unfrequently,
before any pain in the thigh or groin is experienced, the calf of the
leg will be found swollen, painful, and hard, as if it were attached
to the bone, and can not be shaken, while the calf of the other
limb, on being shaken, will be found flabby and movable. It is
not unusual for the buttock, and labium pudendi of the diseased
side, to share in the abnormal action.

The swelling is hard and elastic, the skin is tense, shining, white,
and exceedingly sensitive to the touch, with an augmented temper-
ature, and although yielding to pressure, does not leave a pit,
except upon the parts which are free from pain, or at the decline
of the disease. In the direction of the femoral vein, a hard,
exceedingly painful cord may be felt, which is the thickened and
indurated vein ; sometimes, an enlargement of the inguinal glands

638

AMERICAN ECLECTIC OBSTETRICS.

may be detected. If the limb be punctured, only a few drops of a
gelatinous fluid will be discharged. As the swelling progresses,
there is, generally, some abatement of the pain, but not an entire
removal.

The pain accompanying the swelling is very severe, and is much
aggravated by any motion of the limb, or even by the slightest
pressure. It is usually more intense on the inside and back of the
thigh, in the direction of the internal cutaneous, and crural nerve.
Sometimes it commences in the back and hip-joint. It is constant,
though there may occasionally be slight remissions; and the best
position in which the limb can be placed is to have it slightly ele-
vated upon an inclined plane, having an angle of from 6° to 10°;
or, it may be flexed both at the knee and hip-joints. In a depressed
or depending position, the pain will be much augmented. From
the commencement of the attack, the affected limb feels heavy and
stiff, and, as the disease progresses, the patient will be unable to
move it, not only from the excessive pain produced, but, because
the limb has become powerless.

In connection with the pain and swelling, there will be more or
less fever, headache, nausea, or vomiting, quick and feeble pulse,
giving frequently 130 to 140 beats in a minute; thirst, restlessness,
and sleeplessness. The bowels are usually constipated; the urine
turbid, and small in quantity; the lochia are suppressed, or fetid,
sometimes the discharge remains unaltered; together with other
symptoms, varying in degree, but indicative of the general dis-
turbance to the constitution. These disappear gradually as the
pain diminishes, leaving the patient extremely debilitated. Some-
times, there will be a copious perspiration throughout the whole
course of the disease, which will debilitate the patient very much.

It is very seldom that phlegmasia dolens attacks both limbs at
once ; though it may happen, that when the pain and swelling of
the limb first attacked subsides, the disease will manifest itself in
the other one. It usually lasts from four to six or seven weeks,
though the acute stage may continue for only ten or fifteen days.
It may terminate in resolution, the swelling disappearing, and per-
fect use of the limb being restored ; or, the swelling may take place
slowly, the female not wholly recovering the use of the affected limbs.
Suppuration, with ulceration, occasionally occurs, the consequent
exhaustion eventually destroying the woman. And sometimes,
death occurs either suddenly, as for instance, when the patient
raises herself in the bed, or it may take place gradually from the

TREATMENT OF PHLEGMASIA DOLENS.

639

secondary affections induced. Most generally, the acute symptoms
are followed by a chronic form, in which the limb never returns to
its original size, and remains almost powerless through life.

DIAGNOSIS. — This affection may be known, by its occurring
within a few days or weeks after delivery ; by the pain down the
affected limb ; by the hardness of the swelling ; the attending fever ;
and the hard, cord-like, and painful condition of the femoral vein.
If the calf of the leg is firm, hard, immovable, and painful on being
compressed, and, if pain is produced in the upper part of the
limb on rotating it, these are positive indications of crural phlebitis.
The left side is more commonly attacked with the disease than the
right.

PROGNOSIS. — The disease seldom proves fatal. The less severe
the fever and the swelling, the milder will be the attack. "When
a favorable change is about to occur, the pain gradually diminishes,
leaving a numbness of the leg for some time; the swelling softens
and becomes oedematous, pitting upon pressure.

POST-MORTEM APPEARANCES.— The cellular membrane
of the limb will be found distended with effused serum. The affected
vein will be obliterated by adhering clots of blood, or coagulable
lymph ; its parietes thickened ; its inner tunic of a deep color ; and
pus may be contained within its canal. Pus may likewise be found,
together with evidences of inflammatory action, in the absorbents ;
small abscesses may be observed in the substance of the affected leg;
and frequently, traces of secondary affections in the joints, cavities,
etc., may be present.

The veins most commonly attacked, are the femoral, iliac, epigas-
tric, spermatic, uterine, and vaginal, the saphena, and the vena
cava.

TREATMENT. — During the acute stage, the indication is to
allay inflammatory action ; and in the second or chronic stage, to
promote absorption of effused fluid and restore the venous circu-
lation.

To fulfill the first indication, both general and local measures
will be required. Among the general measures, the first which
demands our attention, provided there is no diarrhea, is the admin-
istration of a brisk cathartic, as, for instance, the compound powder
of Jalap, with some nitrate, or bi-tartrate of Potassa added ; or, a
combination of Podophyllin, Leptandrin, and one of the above
salts of Potassa. The purgative should be administered in a dose
sufficient to act thoroughly, without a repetition of it within four

640

AMERICAN ECLECTIC OBSTETRICS.

or five hours. It not only empties the intestinal tract, removing
any existing morbid accumulations, but it likewise has a revulsive
effect, and renders the system more susceptible to the beneficial
influences of subsequent medication. If necessary, the cathartic
may be repeated again ofa the second or third day ; and during
the whole period of the acute stage, the bowels must be kept free,
causing one evacuation daily. The means heretofore named for
this purpose may be employed ; but I prefer an infusion of two
parts of Leptandra root, and one part of the root of Blue Flag
(Lis versicolor), which may be given every hour or two in doses of
a tablespoonful, or sufficiently often to produce the desired result.

After the cartharsis, agents must be administered for the purpose
of allaying the inflammation and lessening the pain. Equal parts
of the saturated tinctures of Colchicum seed, and Black Cohosh
root (Cimicifuga rac.) may be combined, and given in half flui-
drachm or fluidrachm doses, which may be repeated every two,
three, or four hours, according to the degree of inflammatory action,
and the influence of the remedy. Sometimes and more especially
when the pain is intense with high inflammation, from three to eight
or ten drops of the tincture of Aconite root, may be added to each
dose of the above compound, or, to every other dose, according
to the influence it exerts upon the system. The above agent will
most generally be found to act promptly in subduing the more
active symptoms.

Other agents, of equal value, may be used to fulfill the same indi-
cation ; thus, the tincture of Gelseminum, administered either
alone, or in conjunction with the tincture of Aconite, will be found
to exert a prompt and beneficial influence. Norwood's tincture of
Veratrum Viride, has been used by many practitioners, and with
excellent results, both in this affection, puerperal fever, and many
other febrile and inflammatory conditions. In one point this tinc-
ture resembles that of Gelseminum ; thus, its action appears to
depend upon a volatile principle, for, if prepared from the dried
root, or left exposed to the atmosphere, its effects are not so bene-
ficial nor so prompt as when prepared from the fresh root, and
kept in well-stopped bottles.

Occasionally, when there is no mitigation of the pain by the
above means, the sulphate, or acetate of Morphia may be pre-
scribed in doses of one-fourth, or, one-half a grain, and repeated
as may be required ; this may be given more particularly when the
patient is restless, irritable and sleepless.

TREATMENT OF PHLEGMASIA DOLENS.

641

Diuretics are an important part of the treatment, and those of a
non-stimulating character only should be allowed. A cold infusion
of Cleavers {Galium aparine) may be used; or, an infusion of
equal parts of , Cleavers, Maidenhair (Adiantum pedatum), and
Elder Blows (Sambucus Canadensis), may be prescribed, and, in all
cases, these diuretics should be used freely. Hair-cap moss (Poly-
trichum juniperum), will likewise be found very beneficial as a
diuretic; an infusion may be administered of this plant only, or in
combination with some of the preceding diuretics. And when the
patient becomes averse to one diuretic infusion, another should be
substituted.

Gastralgia, or a burning pain in the epigastric region, is some-
times present, and may be relieved by the administration of a
powder composed of nitrate of Bismuth ten grains, Lupulin two
or four grains, and this may be repeated every four or five hours.
An infusion of Peach-leaves will also relieve it, as well as the tinc-
tures of Gelseminum and Aconite.

Among the local measures, fomentations to the affected limb
occupy a prominent position. Vinegar in which hops have been
boiled, or, an infusion of Water Pepper (Polygonum pun datum) ^
may be applied to the whole limb by means of flannel cloths.
Sometimes a warm application will be found the most advan-
tageous, at others a cold one; this point must be determined, by
the practitioner, according to the peculiarities of each individual
case. Generally, cold applications will be preferable, but when
they occasion a sense of cold or chilliness, they are contra-indi-
cated, and the warm applications must be substituted. Sometimes
a bandage may be loosely applied along the whole limb from the
toes to the groins, which should be kept constantly moistened
with cold or warm water, or with a mixture of water and spirits,
and frequently, a solution of muriate of Ammonia will be found
most valuable; be careful not to bandage tightly in the acute
stage.

In the early part of the attack, much advantage may be derived
from the application of cups or leeches on the limb, along the
course of the pain, and many of our practitioners have beneficially
employed these. I have always, heretofore, succeeded without
them, but should not hesitate a moment to use them in any case
where I considered it necessary.

But, of all the applications to the limb during the intensity of
the attack, I know of none superior or equal to recent Stramo-

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AMERICAN ECLECTIC OBSTETRICS.

nium leaves when these can be obtained. They should be bruised,
and the whole limb covered with them. It is considerable trouble
to collect and prepare the remedy in this manner, but a similar
benefit, though in a minor degree, may be obtained by bruising the
leaves, and placing them in hot, not boiling water, and applying this
infusion, either warm or cold, by means of flannel cloths. The appli-
cation may be extended across the hypogastric region with
advantage. Dried Stramonium leaves do not exert the same
prompt and decided influence over the inflammation, but their
action may be improved by combining them with an equal quantity
of Lobelia, and applying as above.

Blisters applied more especially to the groin of the affected
limb, or along the course of the pain, have been used with favor-
able results by many practitioners, though I have never found it
necessary to employ them in my own practice. I have, however,
frequently and beneficially applied a sinapism across the sacral and
lumbo-sacral regions, and I prefer this to a blister on these points,
on account of the decubitis being principally and for some time
upon the back, or nearly so.

The patient should be kept as quiet as possible during the
inflammatory stage, the apartment should be kept at a moderate
temperature, and she must be restricted to a low and cooling diet.
After the removal of this stage, a more nourishing diet may be
allowed, and should there be much debility, tonics, or wine may be
judiciously administered.

After the inflammatory symptoms have been subdued, measures
must be taken to promote absorption and restore venous circula-
tion. Internally, the mixture of the saturated tinctures of Cimici-
fuga and Colchicum seed may be continued together with the diu-
retics. In the advanced chronic stage alteratives must also be used,
as some preparation of Iodine, the compound syrup of Stillingia and
Iodide of Potassium, or, the compound syrup of Yellow Dock
may be substituted. Muriate of Ammonia may be beneficially
employed at this period of the disease, five or ten grains in solu-
tion, or syrup, may be administered every two or three hours. Or,
it may be added to the above syrups instead of the Iodide of
Potassium.

The limb should be carefully bandaged from the toes to the
thigh, but not so tightly as to render the patient uncomfortable.
As the baudage will require to be removed and re-applied twice in

TREATMENT OF PHLEGMASIA DOLENS.

643

the course of every twenty-four hours, these periods may be
improved for the purpose of applying friction, as well as some
stimulating liniment or wash, to the limb; and the bandage may
even be kept moist with the same stimulant, or with a solution of
muriate of Ammonia. Currents of galvanism or electro-magne-
tism may likewise be passed through the limb once or twice daily,
more especially in the advanced chronic stage. Of course, as in
the acute stage, the limb should be kept in an elevated position,
for such a length of time as may be deemed proper, in order to
render the cure thorough and permanent. An irritating plaster
over the sacrum, or, over the lumbo-sacral region, ought never to
be omitted in the second stage — it tends greatly to facilitate the
cure. The sore produced by it should be kept discharging as long
as the patient can bear it. And after it has healed, if its further
employment be indicated, do not hesitate to apply it. I know it
is exceedingly painful and annoying, but its advantages, in this
disease, repay its disadvantages a hundred times over.

"Whenever the lochial discharge is fetid, whether in the first or
second stage of the disease, tepid water, an infusion of Marsh-
mallow root, or, diluted pyroligneous acid may be injected into the
vagina, two or three times a day.

A ny ulcers of the leg, caused by the disease, which may present
themselves, are to be treated upon the same principles as other
ulcers.

In the second stage, the patient should be allowed to sit up more
or less during the day, but never with the limb in a depending
position ; the diet should be nourishing and of easy digestion, and
tonics, wine in moderate quantity, or wine and Peruvian bark
must be allowed when there is much debility. In the more
advanced stages of the disease, sea-bathing has been recommended,
and may, probably, be occasionally useful.

The above treatment will, in the majority of instances, effect
a perfect cure, if it be commenced sufficiently early, but the prac-
titioner must not be disappointed in occasionally finding patients
who, notwithstanding the active and energetic means employed,
recover only to carry for the remainder of their existence, a debili-
tated and enlarged limb.

644

AMERICAN ECLECTIC OBSTETRICS.

CHAPTER XLIX.

PHREN1TIS PUERPERAL MANIA TREATMENT OF PUERPERAL MANIA INTESTINAL IRRITA-
TION ACUTE TYMPANITIS — DIARRHEA.

Inflammation of the brain and its membranes, is sometimes met
with in puerperal females; there will be headache, flushing of the
face, throbbing of the arteries, intolerance of light and sound, deli-
rium, and all the symptoms of an ordinary phrenitis. The treat-
ment will not vary from that usually pursued when the inflamma-
tion occurs at other periods.

It may be proper to observe here, that for five or six weeks after
delivery, females are subject to severe cerebral derangement, from
eating oysters, clams, and indigestible articles of diet, or from par-
taking too freely at meals. The most common symptoms in such
cases are, headache, delirium, insensibility, convulsions, and death.
They must be actively treated by the usual means for such dis-
turbance, but it will frequently be found that treatment produces
no amelioration of the symptoms, the disease steadily advancing
toward a fatal termination.

PUERPERAL MANIA, is more frequently met with than
puerperal phrenitis, and is said to occur more frequently among
unmarried females than others. Those of an excitable or very sen-
sitive disposition are the most liable to it, though no constitution
or temperament is exempt. It may occur during gestation, during
parturition, or subsequently : the most usual periods of attack are
a few hours or days after labor, before the system has fully
recovered from the shock ; and, at some period previous to wean-
ing, when the constitution is suffering from the debilitating influ-
ence of lactation. It may continue for a few days, or months, and
frequently many years may intervene between the commencement
of the attack and the mental restoration; occasionally the mania
continues through life.

There is a species of delirium which is occasionally observed
when the head of the child is passing through the os uteri, or
when it is distending the perineum, and which is probably caused
by the excessive pain experienced at these times. It is not per-
manent in its character, generally disappearing shortly after the
passage of the child through the parts. The female is frequently

PUERPERAL MANIA.

645

aware of the wildness and absurdities of her thoughts and expres-
sions during this period.

Puerperal insanity is frequently hereditary, all the females of
a family, from generation to generation, being subject to more or
less mental derangement at the parturient period; and when this
is known to be the ease with a pregnant female, the practitioner
should endeavor to ward off an attack by proper treatment during
the gestating months. A common predisposing cause is the
extreme susceptibility or excitability of the nervous system and
brain to which pregnant females, as well as those who give suck,
are subject, and which renders them exceedingly liable to morbid
impressions.

Mental emotions, as a great anxiety relative to her condition, or
a state of depression, or a severe fright occurring during pregnancy,
may likewise predispose the female to an attack of mania ; and a
very common predisposing cause is derangement of the digestive
functions. Profuse hemorrhage has also been considered a predis-
posing cause.

The exciting causes are many ; as irritation of the breasts, uterine
irritation, suppression of lochia, the vascular disturbance caused by
labor, suckling, nervous shock of labor, cold, and frequently it
occurs without any assignable cause.

SYMPTOMS. — These do not vary essentially from those which
occur during the insanity of non-pregnant females, or of males.
The attack may come on suddenly, or it may take place gradually,
and is frequently preceded by more or less headache, nervous irrita-
bility, and sometimes derangements of the digestive organs. Some-
times the female will be restless and sleepless, incessantly talking,
and expressing herself in a wild, disconnected, and most absurd
manner; at other times she will be depressed and melancholy.
Females have been known to escape the watchfulness of their
attendants when attacked by puerperal mania, and roam for a great
distance from home, even through snow and severe cold weather,
and without any other result than a restoration to sanity ; which,
however, would probably have occurred independent of such
exposure and exercise.

It would occupy more space than would be necessary in the
present work, to detail the various symptoms which may occur in
this disease : suffice it to say, that though there may be some pecu-
liarities attending it, yet the general symptoms present the same

646

AMERICAN ECLECTIC OBSTETRICS.

features as those of the several varieties of insanity met with at
other times.

There are two opposite conditions of the vascular system in this
disease ; one is accompanied with more or less fever, a quick pulse
ranging from 120 to 140 beats in a minute, headache, throbbing of
the carotids, flushed face, intolerance of light, great mental excite-
ment with incessant raving, it being almost impossible to restrain
the patient. The tongue is usually coated with a slimy fur; the
urine is turbid and scanty ; the secretion of milk diminished, as
well as its nutritive qualities; the bowels constipated; the lochia
suppressed, or natural ; and often a peculiar and offensive odor
emanates from the various excretions. If a disposition to commit
violence is present, it is commonly directed against others, and not
against herself.

In the other condition, |the pulse is feeble and but slightly accel-
erated ; the temperature of the surface is natural or diminished ;
there is but little or no headache; the tongue is -coated white ; the
bowels are constipated ; the countenance is pale and sunken,- but
sometimes calm and tranquil, with a gradually progressing emacia-
tion. In this condition the patient is usually in a depressed or
melancholy state, and is frequently aware of her situation : there is
more or less mental apprehension, perhaps a religious mania, with
great physical inactivity,' and a strong tendency to commit suicide.

Puerperal mania may terminate in a few hours, the mind being
perfectly restored ; or it may continue for months or years, with
ultimate recovery ; or it may, as has been observed in a few cases,
be permanent and incurable ; or it may terminate in death, espe-
cially in the raving variety, which is attended with quick pulse and
febrile symptoms.

DIAGNOSIS. — Puerperal mania may be confounded with phre-
nitis ; but although the pulse be quick in mania, it is not so sharp
and hard as in cerebral inflammations, nor is there such a high
degree of the heat of the surface and of the febrile symptoms : in
phrenitis there is an intolerance of light and sound, which is seldom
the case in mania : phrenitis is attended with fever, headache, and
other inflammatory symptoms, for some time before delirium mani-
fests itself, while in mania the incoherency exists from the com-
mencement.

It may be determined from congestive headache, by observing
that this does not commence with delirium: and from delirium
tremens, by learning the history of the case, the previous habits"of

PUERPERAL MANIA.

647

the patient, and by attending to the attack, which, in delirium
tremens, is not sudden, and is attended with a cold, clammy skin,
profuse sweats, tremors, and tremulousness of the tongue.

When a pregnant female is subject to " frequent hysterical attacks,
unaccountable exuberance or depression of spirits, morbid aptitude
to exaggerate every trivial occurrence and attach to it great import-
ance, suspicion, irritability, or febrile excitation; or, what is still
more indicative, a soporous state, with very quick pulse, then," says
Burrows, " the supervention of delirium on labor must be dreaded."
And to these symptoms Ramsbotham adds, as a prominent fore-
warning, a great loss of memory.

PROGNOSIS. — The more serious form of puerperal mania, is
that which is manifested by a greater or less degree of excitement.
When it occurs immediately after delivery, with constant and rapid
pulse, the paroxysms being furious and ungovernable, it is much
more dangerous to life than when it occurs later, and with milder,
symptoms. Free evacuations from the bowels are favorable, as are
likewise a decrease of the pulse, the patient obtaining some sleep,
and not being much prostrated. A rapid pulse, increasing in fre-
quency, is generally indicative of a fatal result, the mania being
probably connected with an inflammatory action of some of the
pelvic or abdominal viscera. The melancholy form of puerperal
mania is more permanent, and more difficult of removal, than
the raving. " Mania is more dangerous to life — melancholia to
reason." — (Gooch.)

TREATMENT.— We must attend to the symptoms as they
manifest themselves, endeavoring to overcome the excitable condi-
tion of the brain and nervous system, without occasioning or allow-
ing any great amount of debility to ensue. The bowels must be
opened occasionally by some mild, stimulating purgative, and kept
free, during the intervals, by gentle laxatives. The compound
powder of Jalap will answer as a purgative; or Podophyllin, Lep-
tandrin, and Xanthoxylin may be given. As a laxative, the powder
of Rhubarb and Bicarbonate of Potassa may be used, or the com-
pound syrup of Rhubarb and Potassa. If the patient can not be
persuaded to take these, stimulating enema may be used, as Castor
Oil, with the compound tincture of Lobelia and Capsicum added.

One or two emetics administered at the commencement of the
attack, has frequently produced results of a decidedly beneficial
character ; but it must be recollected that they are injurious when

648

AMERICAN ECLECTIC OBSTETRICS.

there is prostration of the system, with a feeble, rapid pulse, pale
face, and cold surface.

Counter-irritation will be found of great value. The whole sur-
face should be bathed with a warm alkaline solution to which some
alcohol has been added, after which a sinapism may be applied the
whole length of the spinal column, together with friction and stim-
ulating applications to the inferior extremities from the hips down-
ward. In connection with this, the application of tepid or cold
water to the head three or four times a day as a douche, will prove
beneficial ; or cold applications may be constantly kept on the head.
When there is much activity of the circulation, with preternatural
heat of the head, the hair should be cut off, and sometimes leeches
or cups to the temples and nape of the neck will be advantageous.
The sinapisms may be changed alternately from the spinal column
to the extremities, and vice versa, removing them when considera-
ble redness of the surface to which they have been applied is pro-
duced. An irritating plaster, as for instance, the compound Tar
plaster, may sometimes be advantageously applied to the nape of
the neck or between the shoulders ; but in order to derive an imme-
diate benefit from it, vesication should first be effected by means of
a blister.

After the bowels have been evacuated, sedatives should be exhib-
ited. The tincture of Gelseminum will be found exceedingly valu-
able ; it may be used alone, or in the following combination : Take
of tincture of Gelseminum one fluidounce, tincture of Belladonna
two fluidrachms, sulphate of Quinia sixteen grains ; mix, and
administer half a fiuidrachm for a dose, repeating it every hour,
until the peculiar influence of the Gelseminum is obtained, after
which it should be given every three or four hours, or at sufficient
intervals to maintain, but not increase, this influence. The tinc-
tures of Stramonium, or Hyoscyamus may be substituted for that
of the Belladonna. Other agents may also be employed with ben-
efit, as a powder composed of sulphate of Quinia one grain, sulphate
of Morphia half a grain, extract of Belladonna (dried) one-eighth of
a grain; mix for a dose, which may be repeated every hour. In
some cases, two parts of the compound tincture of Virginia Snake-
root, may be added to one part of the tincture of Gelseminum, of
which a fiuidrachm may be administered every hour until a seda-
tive influence is obtained. Sleep and quiet are the patient's great
restoratives; and every justifiable means should be adopted to pro-
cure sleep.

PUERPEKAL MANIA.

649

The patient should be kept in a darkened room, free from noise or
disturbance, and an experienced nurse should be obtained who is
accustomed to attend such patients, and who understands how to
manage their whims and caprices — for a scolding, contradictory,
or inattentive nurse, will effect more injury than benefit, by increas-
ing the excitement and fury of the patient. If the female be very
boisterous and unruly, attempting violence, it may become neces-
sary to employ some restraint, as a strait waistcoat, but this must
not be used without it is absolutely required; frequently, an obser-
vation to the nurse, in the presence of the patient, that this will
have to be employed, will at once calm the most raving maniac.
She should never be left alone, and the windows of the apartment
which she occupies should be well secured, and all knives or other
dangerous instruments, with which she might effect suicide, or
injure others, must be removed. The diet must be nutritious, and
should there be much depression of the system, stimulants will be
required. It is frequently the case that the patient will refuse to
take either food or medicine. A proper amount of food must be
taken within the twenty-four hours, and the medicine may fre-
quently be concealed in it ; but when she obstinately refuses food, a
cold douche, if not contra-indicated, a reference to the strait waist-
coat, or persuasion, may succeed in causing her to eat. Sometimes,
if left within her reach, she will eat the food when under an idea,
probably, that she is unobserved. It is always proper, when it can
be accomplished, after the severity of the first attack has subsided,
to have the female exercise as much as possible in the open air, but
not to such an extent as to cause fatigue. There is frequently an
ansemic condition of the system in this disease, which the practi-
tioner should carefully observe, and for which some ferruginous
preparation will be found to act like a charm.

In the early stages of puerperal insanity, it is not prudent to
allow the female to see her husband, child, or friends, as it gener-
ally proves injurious, by giving rise to ideas, or mental efforts,
which increase the cerebral disturbance; but, in the passive or
chronic stages, short and distant interviews are frequently followed
by an abatement of the mental derangement. And, whenever it
is deemed desirable that she should see her child, she must not be
permitted to handle it, lest in a sudden maniacal fit she should
destroy, or seriously injure it.

When there is reason to anticipate an attack of*mania at the
parturient period, either from a hereditary predisposition, from,
42

650

AMERICAN ECLECTIC OBSTETRICS.

insanity at a former labor, or from the symptoms heretofore
described, a proper course of treatment should at once be insti-
tuted. The bowels, especially, should be kept regular, and no
crude, indigestible, or other improper articles of diet should be
allowed. All sources of irritation should be removed, the mind
must be kept free from exciting or depressing influences; coition
during the gestating period must be positively forbidden; moder-
ate exercise must be advised, but not to the extent of fatigue; the
female should not be allowed to remain alone, and the company
permitted to visit her must be carefully selected, refusing admit-
tance to those who occasion too great a degree of mirth, as well as
to those who are fond of dispensing horrible and melancholy news,
whether true or false; pleasant, cheerful, and prudent individuals
only should be selected. If the patient be sleepless, Scutellarin,
Asclepidin, Lupulin, or some similar agent may be used; or, an
infusion of the herbs may be drank through the day. Plethora
must be overcome by diuretics; anaemia by chalybeates; and de-
bility by bitter tonics and such other invigorating measures as may
be found serviceable. The compound syrup of Partridgeberry,
will be of advantage in many instances. Should there be a con-
stant, dull, or severe pain in the head, cooling lotions to the head,
sinapisms to the back of the neck, with rest and quiet, will, in
conjunction with the other means, generally remove it, and pre-
vent the attack at the puerperal season.

Females are subject to a condition slightly resembling peritonitis,
and which has been named INTESTINAL IRRITATION, by
Dr. Marshal Hall, and Acute Tympanites, by Dr. Ramsbotham. It
may be owing to some peculiar excitement or irritation of the
lining membrane of the intestinal tube, occasioned by a constipated
condition of the bowels, improper food, or irregularities of diet,
which, by debilitating the muscular fibers of the intestines, causes,
soon after delivery, a sudden development of gas.

The attack occurs generally two or three days after delivery,
being ushered in with rigors, which are more or less severe, and
are succeeded by increased heat and dryness of the skin; rapid
pulse, fuller and firmer than in peritonitis, or fluttering and trem-
ulous; tongue red, sometimes furred; countenance changed, but
not as anxious as in peritonitis; severe headache; intolerance of
light and soifhd; constant wakefulness; and often delirium. At
an early period the abdomen swells rapidly and to an enormous

INTESTINAL IRRITATION.

651

extent, being very tense and painful, and the pain is aggravated
by pressure; frequently the transverse colon can be distinctly
traced. The secretion of milk becomes suspended, as well as the
lochia ; the patient lies upon her back in a state of languor, being
averse to conversation, or any kind of disturbance; the legs are
usually drawn up, and the female appears indifferent to everything
about her. As the disease progresses, the pain, and swelling of
the abdomen increase, the tongue becomes dry and brown, with
vomiting of offensive matter, hiccough, low, muttering delirium,
subsultus tendinum, and other symptoms common to the last stage
of fever.

DIAGNOSIS. — The principal distinguishing mark between this
disease and peritonitis, is the period of abdominal enlargement.
In peritonitis the first symptom is pain, and the swelling does not
come on until the disease has existed sometime; in the disease
under consideration the swelling manifests itself first, and the pain
is subsequent, being, probably, occasioned by the inordinate infla-
tion of the intestines, together with a morbid state of the nerves.
In peritonitis the patient is anxious as to the termination of her
disease ; in the present affection there is a great loss of nervous
energy, occasioning a complete state of listlessness.

PROGNOSIS. — A subsidence of the tenseness, swelling, and
pain of the abdomen, with the pulse becoming more natural, the
tongue clean and more moist, the skin cool and soft, the bowels
becoming free with expulsion of large quantities of wind, vomit-
ing ceasing, intellect unimpaired, a desire for food, and an atten-
tion to surrounding circumstances, are indicative of recovery.

TREATMENT. — Should there be any undigested food upon the
stomach an emetic may be administered, to be followed by a pur-
gative conjoined with some carminative. The compound powder
of Jalap, may be given in conjunction with some essence of Pep-
permint, of Nutmeg, tincture of Ginger, or tincture of Prickly-
Ash berries. At the same time an injection should be given, pre-
pared as follows : To one quart of a strong decoction of Senna
and Boneset, add a pint of molasses, two drachms of pulverized
Lobelia seed, and one ounce of tincture of Prickly-Ash berries.
This should be used at one injection, and may be repeated in ten
or fifteen minutes, if no evacuations are induced.

After the bowels have been freely relieved, the following powder
may be given, and repeated three or four times a day : Take of
compound powder of Ipecacuanha and Opium five grains, Diosco-

652

AMERICAN ECLECTIC OBSTETRICS.

rein two grains, Ginger two grains ; mix for a dose. Or, Podo-
pliyllin two grains, Dioscorein eight grains, and Hydrastin four
grains, may be mixed together and divided into four powders ;
one of these is a dose, and which may be repeated three or four times
a day. Much benefit will also be derived from the exhibition of a
fluidrachm of the tincture of Prickly-Ash berries every two or
three hours, in some water, or, in an infusion of Dioscorea Villosa.
These agents allay irritation, aid in expelling the gas, and gradu-
ally restore the tone of the intestines. Cloths wet with hot water,
or hot fomentations of Hops and Tansy, or other bitter herbs, will
prove highly valuable when applied over the abdomen.

The oil of Turpentine, exhibited externally and internally, has
been highly extolled in this disease. Externally, it is to be applied
over the surface of the abdomen ; internally, one or two flui-
drachms, mixed with the white of an egg, may be given, and the
dose repeated every four hours ; or, if rejected by the stomach, an
ounce of it may be injected into the rectum.

Should any inflammatory symptoms be present, they must be
combated by the means already explained.

The patient should be kept quiet, her room being somewhat
darkened, and no visitors should be permitted to enter. After the
evacuation of the bowels, when the swelling begins to subside, a
nutritious, easily-digested diet should be allowed, with some stim-
uli if required. Tonics may also be exhibited. I know of no
better agent to rapidly restore the tone of the intestines, after all
the dangerous symptoms have been removed, than a powder com-
posed of Ginger, Dioscorein, and Asclepidin, each two grains ; mix
for a dose and repeat every three or four hours through the day.
These should be accompanied with an occasional dose of the tincture
of Prickly-Ash berries. Or, the compound powder of Golden
Seal may be used with benefit, in doses of half a drachm, repeated
three times a day.

DIARRHEA, may precede labor, continuing after delivery, or it
may occur shortly subsequent to delivery, it frequently proves obsti-
nate and fatal. The bowels should be evacuated by the compound
syrup of Rhubarb and Potassa, or, the compound powder of Rhu-
barb, after which either may be continued in smaller doses. If the
diarrhea continues without improvement after their employment for
a day cr two, omit them, and substitute a powder composed of Cau-
lophylhn Geraniin, and Leptandrin, each, one grain: mix for a

INFLAMMATION OF THE BREASTS.

653

dose, which may be repeated every hour or two ; at the same time
the patient should drink freely of some astringent infusion, as of
Blackberry root, Beth root, etc. If cramps or spasms are present,
the compound powder of Ipecacuanha and Opium, or, the com-
pound powder of Yellow Ladies-slipper, may be given by mouth,
or by injection, if the stomach will not retain them. Should these
means fail to remove the diarrhea, the tincture of chloride of Iron,
will then have to be used according to the method advised on page
631. The diet will require to be strictly regulated until the cure is
effected.

In diarrhea occurring after delivery, the practitioner should care-
fully watch for a prolapsus of the uterus ; this displacement of the
organ will frequently be found present, rendering the diarrhea
intractable to all agents, until it has been reduced. On several occa-
sions, the treatment above-named has failed to effect any benefit,
until after a reduction of the prolapsus, when a gradual cessation
of the diarrhea followed.

CHAPTER L.

INFLAMMATION OF THE BREASTS MAMMARY ABSCESS — EPHEMERAL FEVER WEED — MILIARY

FEVER SORE MOUTH OF NURSING WOMEN.

INFLAMMATION OF THE BREASTS, of nursing women is
frequent occurrence ; it may of happen at any period of lactation,
but is most commonly met with during the first month after deliv-
ery. At first, the inflammation is usually limited to a circumscribed
spot, but continues to extend into the surrounding parts, until the
whole breast becomes involved; occasionally, the whole breast,
may be affected from the beginning, and, sometimes, both breasts
become inflamed simultaneously. There is a strong tendency to
suppuration in inflammation of the mamma, which is often very
difficult to prevent.

This affection may be caused by an increased accumulation of
milk within the lactiferous tubes, occasioned by the mother not
allowing her child to suck, on account of tender and excoriated
nipples, or, perhaps, because she absents herself from her child,
frequently and at long periods, in order to enjoy parties and places
of amusements, thus neglecting to give to the distended breasts

654

AMERICAN ECLECTIC OBSTETRICS.

the relief they require. A neglect of this kind, repeated several
times, will readily induce an abnormal condition of the glands.
The disease may also be produced by cold, and this is undoubtedly
a common exciting cause. It may likewise follow mechanical
injuries, as blows, compression from tight-lacing, etc., and may be
induced by strong mental emotions. All femal.es are subject to it,
but those of a strumous diathesis, or who are delicate and feeble,
are especially so. It is more common to primiparse; but, many
females suffer from it after each confinement.

SYMPTOMS. — Generally, the first symptoms experienced are
more or less severe rigors, followed by fever ; a shooting pain in
the breast, is complained of by the patient, which is aggravated by
pressure, and accompanying which there is a gradual swelling of
the organ. Upon examining the breast at an early period, a cir-
'cumscribed hardness will be observed, within which the pain is
located, and the skin over which presents a natural appearance.
As the disease progresses the swelling becomes more extensive, the
pain more severe, the skin hot and shining, and of a dusky-red
color, and finally the swelling becomes soft and slightly oedema-
tous, with more or less marked fluctuation, indicative of the forma-
tion of pus. The symptoms now increase in severity ; the patient
becomes fretful in consequence of the severe pain, distressing
shiverings, want of sleep, and nocturnal perspirations, all of which
occasion a gradual loss of appetite, strength, and flesh. Sometimes
nausea is present, and not unfrequently an obstinate diarrhea.

The pain is more severe in proportion to the extent and depth
to which the gland is involved. If the inflammation be superficial,
the pus is laudable; if it extend deeply, there is always sloughing
of considerable magnitude present. The suppuration ensues more
rapidly when the inflammation is superficial, or in the cellular sub-
stance under the skin.

This disease is more unfavorable to patients of a strumous habit,
and, though it rarely proves fatal, yet it requires prompt and ener-
getic treatment. It is frequently of tedious and difficult cure, and
has been known to arouse a dormant and inactive predisposition
to disease, into a fatal activity.

TREATMENT.— The indication for treatment is, to promote
resolution; but, if the disease has continued for two or three days,
with considerable heat and pain, resolution can seldom be effected,
and then, means must be adopted to promote suppuration. Sup-
puration usually occurs in ten or twelve days, seldom sooner.

INFLAMMATION OF THE BREASTS.

655

In order to prevent the inflammation from terminating in sup-
puration, the treatment must be commenced by the administration
of an active cathartic. The breast should be bathed two or three
times a day, with some stimulating preparation; I generally employ
a liniment made of equal parts of oil of Cajeput, oil of Sassafras,
Olive oil, and Camphor. After applying this, a warm poultice
or fomentation may be applied, and which should be changed two
or three times a day, at the periods of bathing with the liniment.

Although I have just recommended the application of a fomen-
tation or poultice to the breast, it is only because others have fre-
quently used them with advantage. For the last thirty years
I have never employed any other agent for the resolution of the
disease, than the following ointment, to be applied immediately
after having bathed the breast with the above liniment: Take of
Castile Soap six ounces, good Lard four ounces, yellow Beeswax
two ounces ; finely cut, or shave the soap, add to it the other arti-
cles, and melt the whole together by means of a moderate heat.
When thoroughly melted and incorporated, remove the vessel con-
taining them from the fire, and when nearly cool, add gradually
three fiuidounces of Jamaica Spirits, in which three drachms of
Camphor have been previously dissolved. Continue stirring the
mixture until it is cold.

This ointment has been used with success in every case where it
was applied at an early stage, or previous to suppuration; it
removes all pain and swelling in from twelve to thirty-six hours,
according to the duration of the disease. I have frequently found
it efficacious in cases where the patient had suffered severely for
twenty-four hours, and when I had every reason to believe that
the suppurative stage had actually commenced. I employed it
with constant success for nearly fourteen years before having made
it known to the profession.

The manner of using it is as follows : Cut a piece of linen in
a circular form, of the size of the whole breast, leaving an aperture
in the center sufficiently large for the nipple to pass through. Then
soften a sufficient quantity of the ointment by a gentle heat, and
spread it on the linen. Apply this over the breast, as warm as can
be borne ; at intervals of four or six hours, remove it, soften it as
before, and reapply to the breast immediately after having bathed
it with the stimulating liniment. A fresh application of the oint-
ment will be needed only once in every twenty-four hours ; the

656

AMERICAN ECLECTIC OBSTETRICS.

patient should be kept quiet iu bed, and the breast should be care-
fully supported by a bandage, or some similar means.

During the first stage of the disease more especially, it is of great
importance to keep the breasts as empty as possible, and if this can
not be effected by the infant, other means must be resorted to, as,
some older person accustomed to the business, a young pup, or an
exhausting pump. And any febrile symptoms may be mitigated, as
well as pain and nervous irritability, by the exhibition of the com-
pound powder of Ipecacuanha and Opium, or some similar prepara-
tion. When the pain is excessively severe and the febrile symptoms
run high, it will be better to avoid feeding the infant at all from the
affected breast, and, in some cases, it will be proper not to annoy
the mother and increase her sufferings by requiriug her to give it
suck, but to feed it for a short time in some other way ; if possible,
have a wet nurse employed.

If, however, matter should form, then the employment of poultices
to hasten its progress will be found of considerable value. And
now, the infant should not be permitted to use the milk of the
affected breast any longer, because, with the milk, which has lost
its nutritive qualities, it may be injured by the reception of pus into
its stomach ; the milk must be evacuated by other means. Fresh
Poke-root roasted in hot ashes, in the same manner as the potato,
until it is soft, then mashed and applied over the breast as a poultice,
will materially forward the suppurative stage, though its action will
produce more suffering than the poultices ordinarily employed for
such purpose. The addition of pulverized Lobelia, moistened with
a mixture of warm water and vinegar, to the roasted poke-root,
will materially enhance its value.

" If the abscess is placed superficially, or on the anterior surface
of the breast, and progresses with rapidity, not causing an undue
degree of suffering, it will be better not to interfere with it, but to
allow it to take its natural course.

" If it be deeply^situated, progressing slowly, giving rise to severe
local sufferings, and is attended with a high irritative fever, profuse
perspiration, and want of rest, much time will be saved, as well as
considerable suffering, by opening the abscess at the proper period,
with a probe or lancet, and permitting the pus to escape," being
careful however, not to be in such a hurry as to make an opening
before pus has formed. And always, in opening the abscess, carry
the incision parallel with the lactiferous vessels, so as to avoid
dividing them, as much as possible.

INFLAMMATION OF THE BREASTS.

657

" If there is a thick covering over the abscess, it is improper to
penetrate it with the lancet, because the opening will not succeed in
establishing a free discharge of matter, for, as the aperture closes by
adhesion, the accumulation of matter proceeds, and ulceration will
still continue. On this account, the opening should be made where
the matter is most superficial, and where the fluctuation is distinctly
perceptible, and its size should be proportioned to its depth.

" When the abscesses are very deep, with several sinuses, the best
mode of treatment, is to inject into them a solution of two or three
drops of strong Sulphuric Acid in a fluidounce of Rosewater; and
this may likewise be applied on folds of linen cloth over the bosom,
by which the secretion of milk is checked, and adhesion is pro-
duced." (Sir A. Cooper.)

If the ulcer does not readily heal, or assumes an indolent charac-
ter, apply some sesqui-carbonate of Potassa to it, and dress it with
the red oxide of Lead plaster, or the compound Lead ointment,
treating it similar to ulcers on other parts.

Should there be a troublesome oozing of blood from the wound
made by the lancet, in opening the abscess, it must be treated by the
application of dry lint, with sufficient compression.

In the inflammatory stage, the diet must be light and non-stimu-
lating; during the suppurative discharge, a nourishing diet should
be used, and to support the strength and aid in the formation of
healthy pus, Port Wine and Cinchona, or the compound Wine
of Comfrey, will be required. If there is exhaustion with consider-
able irritability of the system, Morphia and Quinia combined, will
be found advantageous.

Beside MILK FEVER, which has been referred to page 295,
there are two other forms of fever which may be occasionally met
with in practice. One is termed EPHEMERAL FEVER, or
WEED, and is more especially met with in cold, moist weather,
among those who reside in low, marshy places, or in the neighbor-
hood of stagnant ditches. It may likewise be occasioned by cold,
indigestion, constipation, fatigue, mental agitation, Avant of rest,
and improper food. It appears usually in from six to nine days
after delivery, and seldom continues over twenty-four or forty-eight
hours, whence its name, ephemeral. It commences with severe and
long-continued rigors, succeeded by heat and profuse perspiration.
During the shivering there will be pain in the back and various
parts of the system, shrunken features, eyes hollow, skin dry and

658

AMERICAN ECLECTIC OBSTETRICS.

harsh, with the integuments at the fingers' ends livid and corrugated,
thirst, rapid and perhaps irregular pulse, or feeble and indistinct;
and various other distressing symptoms, which increase in severity
as the rigors are about passing off. The hot stage is characterized
by a throbbing of the temples ; great heat of the surface ; flushed
face; severe headache, generally referred, to the forehead and eye-
balls ; soreness of the breasts and of the abdomen ; rapid, full, hard,
and firm pulse ; and a diminution of the various secretions, with
occasional delirium. This is followed, after a longer or shorter
time, by a profuse perspiration, which appears first on the forehead,
neck, and chest, and which is succeeded by an abatement of the
fever, and an amelioration of all the previous symptoms.

This disease may be mistaken for puerperal peritonitis ; but the
violence and long -continuance of the rigors, the absence of marked
abdominal tenderness on pressure, and the very profuse perspira-
tion which is followed by relief, will enable us to distinguish it, as
well as the absence of a return of the paroxysms. It is seldom a
dangerous disease, unless, by improper management, it be allowed
to pass into a continued or intermittent fever.

TREATMENT.— The indications of treatment are to shorten
the various stages of the disease as much as possible. During the
cold stage, apply warmth to the surface, as bottles of warm water,
or warm bricks, etc., to the feet, knees, thighs, and axillse, and
warm flannels over the stomach and abdomen; in addition to
which, warm drinks and cordials may likewise be given ; and, as
the case may require, adopting other means similar to those which
would be employed in the cold stage of ague. As the bowels are
frequently constipated, an active purgative should be administered
either in this or the subsequent stage; sometimes an emetic will
prove advantageous.

In the hot stage, the surface should be bathed with warm, weak
ley-water, and the Sulphate of Quinia exhibited in doses of one,
two, or three grains, every two or three hours : it may be used
alone, or in combination with the compound powder of Ipecacu-
anha and Opium. If there is much nervous irritability, the Vale-
rianate of Quinia will be found a very beneficial agent; and this
may be continued for some days after the cessation of the disease,
to allay the irritability and lessen the disposition to any secondary
attack.

In the sweating stage, the Sulphate of Quinia may be continued
alone, or in conjunction with Prussiate of Iron; and the patient

EPHEMERAL FEVER OR WEED.

659

should use cold, bitter infusions, as of Virginia Snakeroot, Boneset,
Ver vain, Chamomile flowers, etc.

The several symptoms which may present during each stage,
must be met by measures similar to those employed when they
occur in other febrile affections. After the paroxysm has ceased,
the diet should be nutritious, with stimulants if there be much
depression. Exposure to cold should be guarded against, or any
other exciting cause of the disease; and it should be ascertained
by a careful examination whether any derangement of the uterine
system exists, that it may be promptly subdued.

The other febrile affection referred to above, is termed MILIARY
FEVER, : it is still more rarely met with than the preceding,
though in former days it was quite uncommon, and was consid-
ered a formidable disease. It may occur as a primary affec-
tion, and independent of the parturient state ; but more usually it
appears as a symptom connected with puerperal, milk, or epheme-
ral fevers, especially in those cases where perspiration is permitted
to become too profuse. Females of debilitated constitutions are
more subject to it than others. It generally occurs between the
second and twelfth day of delivery, and may be excited by fatigue,
relaxation, impure, over-heated air, stimulants, rich or improper
food, excessive evacuations constipation, and personal uncleanliuess.

It commences with chills, succeeded by fever, and perspiration
of an acid, penetrating odor. There is sickness and languor, with
a hot skin, frequent pulse, depressed spirits or great anxiety of
mind, a great weight about the chest, severe headache, dull and
watery or inflamed eyes, with throbbings within the orbits, tongue
furred white with raised papillae and red edges, ringing in the ears,
and occasionally aphthous ulcerations of the mouth and fauces.
The lochial and lactiferous secretions are diminished or suppressed,
and a pricking or itching of the surface is generally complained of;
occasionally there is a sensation of numbness in the extremities.
The perspiration is usually followed by no mitigation of the symp-
toms. After these symptoms have continued for a few days, the
skin begins to feel rough like the cutis anserina, and in a short
time the eruption appears about the forehead, neck, and breast, from
whence it gradually extends to the trunk and extremities : it rarely
affects the face. It appears in the form of small, red, generally dis-
tinct vesicles, about the size of millet-seed, having a red or inflam-
matory appearance surrounding their base. In a few hours the

i

660 AMERICAN ECLECTIC OBSTETRICS.

vesicles assume a white or yellow appearance, from the change
effected in the lymph contained in them, and in a few days they
dry up, and the crusts fall off in small branny scales. The eruption,
unless the disease be primary, seldom affords any relief to the
symptoms, and may occur frequently and irregularly, should the
fever and perspiration continue. Occasionally, the eruption has
been met with where but little or no fever was present. The dis-
ease is seldom serious unless the perspiration be suddenly checked,
or the eruption recede, under either of which circumstances fatal
results may ensue.

The disease may be determined by the character of the tongue,
the oppression at the chest, and the peculiar, strong, and sour smell
of the perspiration.

TREATMENT. — Keep the room well ventilated and cool, grad-
ually lessening the amount of bedclothes, but being extremely care-
ful not to allow the patient to "catch cold." Give laxatives to keep
the bowels regular, and when there is derangement of the stomach,
an emetic may be useful. The drink of the patient should be cold
and acidulated ; or an infusion of Maidenhair and Elder-blows may
be given, together with a bland, nutritious diet. Sulphate of Quinia
will be fonnd of much service, during the whole course of the dis-
ease.

On the abatement of the febrile symptoms, the diet may be im-
proved and mild tonics employed. Should there be aphthous ulcer-
ations, they may be washed or gargled with a strong infusion of
equal parts of Golden Seal and Blue Cohosh roots, sweetened with
honey ; or a solution of Borax and honey may be used. If the
disease accompanies other affections, especial attention must be
directed toward the treatment of these, for the secondary difficulty
will continue more or less severe, until the primary one is subdued.

"Women who suckle, or who have advanced to the latter months
of pregnancy, are sometimes affected with a sore mouth peculiar
to themselves, somewhat resembling follicular stomatitis, or fol-
licular inflammation of the mouth; other females and men being
exempt from it. It is generally known as the SORE MOUTH OF
NURSING WOMEN-. The most robust constitution, or the
sickly and delicate, are indiscriminately attacked by it ; those, how-
ever, of costive habits, dyspeptic symptoms, and hepatic affections,
seem to be more liable to its attacks than others. And when there
is a tendency to phthisis, or some constitutional disease, the debil-

SORE MOUTH OF NURSING WOMEN.

661

ity produced by it is of a much more serious nature, than in vigor-
ous and sound systems. I have frequently met with it in females
who were liable to attacks of erysipelas, and also those whose con-
stitutions had been injured by the use of mercurials. If this dis-
ease is allowed to go on for any length of time without being
relieved, the morbid irritation of the tongue and fauces extends to
the stomach and bowels, in which case it is apt to prove fatal.
I have known the disease to terminate in death during the third,
fourth, and fifth puerperal week, even after the child had been
kept from the breast.

The children of females laboring under this affection are gener-
ally healthy and robust, being well supplied with milk, the secre-
tion of which is commonly abundant until the last stages, when
the patient being reduced by starvation, this secretion fails. The
means usually employed for common sore mouth, or follicular
inflammation, will not effect any benefit in this disease, unless it be
very mild; and, in many instances, an energetic treatment must be
pursued, or -the patient will die. Death has taken place within a
month from the appearance of the disease, and, again, patients have
lingered for three or four months before the fatal termination. It
is a singular malady, nearly always disappearing upon weaning the
child ; yet weaning is not always necessary, nor is it at all desir-
able, as there is a greater disposition to a return of the disease at
every future accouchement, than in those cases where proper treat-
ment has effected a cure, and restored the constitution to its usual
normal condition. It must be recollected, that in patients who
have been cured of this disease, there will exist a strong tendency
to its return from slight causes, at least until the child is weaned ;
as, from exposures to cold, fatigue, indigestible diet, etc., and which
in consequence, must be carefully guarded against.

This disease appears to depend on gastric and hepatic derange-
ment, in connection with a vitiated state of the blood, and is more
common to those subject to erysipelatous affections, or of strumous
diathesis.

SYMPTOMS.— The accession of the disease is often very rapid
from apparent health — extremely so : within three hours after see-
ing the patient in health, perhaps actively engaged in household
matters, and not suffering from any unusual irregularity of the
stomach and bowels, she will be found with a scalding of the tongue
and fauces, and unable to converse or take food. The first sensa-
tion is uniformly described by the patient as a severe scalding of the

662

AMERICAN ECLECTIC OBSTETRICS.

tongue, with pain, at times intense. There is also a peculiarity of
the tongue, its color, especially in the severer instances, being pink ;
and its edges and the roof of the mouth have a deeper hue of this
color, often accempanied with a most profuse watery discharge from
the mouth, extremely hot, so much so as to give a scalding sensa-
tion to the face when passing over it. The appetite is usually very
good, often ravenous, but no food or drink, except the blandest, can
be taken into the mouth without producing more or less intense
pain : the food must be of a mucilaginous or farinaceous character.
After a continuance of this state of the mouth for a few days or
weeks, slight ulcerations on the end or edges of the tongue mani-
fest themselves, as also about the different parts of the fauces.
Sometimes the disease gradually commences with slight ulcerations
on the tongue, and this general scalding of the tongue and fauces
follows. The bowels are usually constipated, or soon become so;
no fever, but at times excessive irritation of the whole system, in
consequence, probably, of the want of rest; as the continued pain of
the fauces, and the excessive and constant flow of burning saliva
prevent any comfortable rest day or night. The tongue is generally
free from any coat, or it may have a light, white one. Occasionally,
although the surface of the ulcerations is not deep, yet they continue
to increase in width, and the inflammation spreads all over the
mouth. When it extends from the mouth and fauces to the bowels,
diarrhea ensues, and usually, in such cases, the soreness of the mouth
becomes better, but the case is attended with more danger. When
the disease is severe there will be an ansemic condition of the system,
with considerable prostration of the vital energies.

TREATMENT. — In the first two cases of this disease which
I attended, having never seen a description of the disease in any
medical work, I pursued the usual treatment for aphthous ulcera-
tions, and lost my patients ; since which, my success in the treat-
ment of it has been such, as to justify me in recommending the
following plan :

In the severe or obstinate cases, and if the strength or condition
of the patient will admit, an emetic must be administered and
repeated every three or four days; and it should be continued as
long as the symptoms of the case, and the obstinately torpid con-
dition of the liver require. The emetic I usually prefer is the com-
pound powder of Lobelia. In the milder cases emetics may
generally be dispensed with.

After the effects of the emetic have subsided, catharsis must be'

SORE MOUTH OF NURSING WOMEN.

663

produced, which, however, must not be too active, and for which
purpose either the compound powder of Jalap, compound powder
of Leptandrin, compound pills of Podophyllin, compound pills of
Leptandrin, or compound pills of Aloes, may be administered in
sufficient doses ; and, if the pills can not be well swallowed by the
patient, they may be dissolved in water, or triturated with some
mucilage.

Internally, the tincture of chloride of Iron, may be given in
doses of twenty drops in a sufficient quantity of some diuretic infu-
sion, and which should be repeated every two or three hours.
Formerly, I was in the habit of administering alteratives, as the
compound syrup of Sarsaparilla, compound syrup of Yellow Dock
root, or the compound syrup of Stillingia, with a proper propor-
tion of Iodide of Potassium added to the s}7rup used, but, though
these will be frequently found useful, I think the tincture of Iron
above advised, will be found more generally successful, from its
direct influence on the capillary vessels, and the beneficial action
of the Iron in anaemia. A saturated solution of Chlorate of Potassa
in doses of a fluidrachm, repeated every three or four hours, has
frequently proved serviceable. And in some instances, Bromide of
Potash, or of Ammonium in conjunction with Leptandrin and
Alcoholic Extract of Nux Vomica has given prompt relief.

Sometimes diarrhea is present, in which case no purgative must
be administered. The tincture of chloride of Iron in doses of ten
drops, diluted sufficiently, and repeated every hour or two, will be
found to have a most excellent influence over diarrhea, especially
when used in conjunction with a stimulating and astringent injec-
tion, such as a mixture of Tannic Acid one drachm, com'pound
tincture of Virginia Snakeroot, Elm mucilage, of each, half a fluid-
ounce. Mix for an injection, to be repeated immediately after each
stool. Benefit may also be derived in diarrhea, from the following
compound : Take of Rhubarb, prepared Charcoal, each, four
drachms, bicarbonate of Potassa two drachms. Mix in a pint of
Indian-meal gruel, and give a tablespoonful every hour or two,
according to the severity of the disease. Rice-water, Elm-water,
infusion of Blackberry root, or of other vegetable astringents, may
be drank freely.

Any derangement of the kidneys, with scanty, high-colored, and
scalding urine, will require diuretics, as an infusion of Marsh-
mallow root, or of Hair-cap Moss, etc. Sometimes, the Canada
Balsam will be beneficial.

664 AMERICAN ECLECTIC OBSTETRICS.

In nearly all instances of this disease, a deficient action of the
cutaneous vessels will be met with, and which it is absolutely
necessary to remedy. If, as is sometimes the case, the disease
comes on previous to parturition, or immediately succeeding^
delivery, the whole body and limbs should be bathed daily with
a weak alkaline wash, to be followed after drying, with some stim-
ulating application, as Whisky and Water, etc. And as soon after
delivery as may be prudent, the Spirit Vapor bath* should be
administered twice a week, or according to the strength of the
patient. Attention to the surface is an exceedingly important part
of the treatment.

The aphthous condition of the mouth and fauces must also be
attended to locally. A solution of Nitrate of Silver, from sixty to
eighty grains of the salt to a fluidounce of water, will generally be
found useful in allaying the more severe scalding and painful sen-
sations; the whole internal surface of the mouth should be washed
with it once every day, or every other day, and it will be best to
apply it at bedtime, that the female may obtain some sleep after-
ward. Solution of Perchloride of Iron, properly diluted, and
applied one, two, or three times a day to the aphtha?, is likewise
serviceable in many cases ; the same may be said of a weak solu-
tion of Sulphate of Copper. During the day, the mouth and
throat must be frequently washed or gargled with one of the fol-
lowing preparations, a small portion of either of which, say a tea-
epoonful, may be occasionally swallowed with benefit:

1. Take of Geranium Maculatum, Baptisia Tinctoria, Caulo-
phyllum Thalictroides, Hydrastis Canadensis, each, one ounce.
Place the whole in four pints of water, and boil down to two
pints, strain, and add half an ounce of Borax, and half a pint of
Honey.

2. Take of Polygonum Punctatum two ounces, Ligustrum Vul-

*I dislike this name very much, from the fact that there is but very little vapor of
•pirit given off ; the spirit by being burned, heats the air, and it is the heated air
which occasions the perspiration. The term hot-air bath would be preferable. There
are many other matters of a similar nature to which I would invite the attention of
the profession, for instance, the names "antibilious physic," "pulmonary balsam,"
"scrofulous syrup," " sudorific tincture," " ague bitters," "vegetable caustic," "com-
pound cathartic pill," "irritating plaster," etc., all strongly savor of empiricism, and
are calculated to impede rather than advance the interests of our cause. I hope suffi-
cient notice will be taken of these brief suggestions to cause our friends to omit the
use of all such vague, indefinite, and unscientific terms, and employ a nomenclature
better adapted to true medical science.j

SORE MOUTH OF NURSING WOMEN.

665

gare, Hydrastis Canadensis, Ambrosia Trifida, each, one ounce.
Prepare as in the preceding.

3. Take of Geranium Maculatum, Statice Caroliniana, Baptisia
Tinctoria, Hydrastis Canadensis, each, one ounce. Prepare the
same as the preceding.

Undoubtedly, other astringents, and agents which influence
mucous tissues, will be of value.

The diet should be light and easy of digestion, avoiding fats,
stimulating liquors (though wine is indicated when there is great
prostration), gross diet, and everything which will cause acidity
of the stomach, or in any way retard or derange the digestive
functions.

It is always advisable to cure this affection, if possible, without
weaning the child, as the female is thereby rendered less liable to
its recurrence at another parturient period. But, if the soreness
and pain are excessively intense, and appear to be intractable to
all treatment, and more especially when diarrhea is present, wean-
ing may become absolutely necessary, in order to save the patient's
life. In these cases, and also where a strong disposition exists to
a return of the disease at each accouchement, it may be entirely
cured, checked, or its severity very much ameliorated, by regulat-
ing the bowels during pregnancy with the compound powder of
Rhubarb, and preserving, as much as possible, a normal condition
of the system, by some alterative treatment persistently used dur-
ing the whole period of gestation. — Prof. Scudder states that he
has found tobacco smoking to be of more efficacy in this affection,
than any other local application, and he prefers it to all mouth
washes.
43

I

666

AMERICAN ECLECTIC OBSTETRICS.

INFANTILE AFFECTIONS.

It ma^' be proper, before concluding this part of the work, to
make a brief reference to those diseases, and their treatment,
which are more frequently met with in the early weeks of infancy,
and which the obstetrician is almost always expected to attend.

CHATTER LI.

CYANOSIS — RETENTION OF URINE RED GUM JAUNDICE INFANTILE OPHTHALMIA FLATU-
LENT COLIC CONSTIPATION UMBILICAL HERNIA EXCORIATION OF THE NAVEL HEM-
ORRHAGE FROM THE CORD — HEMORRHAGE FROM THE NAT EL NjEVUS MATERNI

TONGUE-TIED HYDROCELE — SWELLING OF THE BREASTS HARE-LIP.

As soon as the child is born, and breathes, a change is effected
in its circulation ; the blood which had partly circulated from the
right into the left auricle, through the foramen ovale, during intro-
uterine existence, as well as that which had flowed through the
ductus arteriosus, from the pulmonary artery into the aorta, now
changes its direction and flows toward the lungs, through the pul-
monary artery. However, cases are occasionally met with, in
which no change of this kind is effected, and the blood continues
to pass from the right to the left side of the heart. From this
circumstance, the blood is imperfectly oxygenized, as manifested
by the livid or blue color of the lips and other parts of the body
which are protected by only a thin cuticle. This condition is
termed Blue Disease, Morbus Cceruleus, and Cyanosis.

The two auricles of the heart form nearly a single cavity, at the
fifth month of pregnancy, in consequence of the imperfect devel-
opment of the septum auricularum; but this septum gradually
matures until at full term the foramen ovale is generally consid-
ered to be nearly or quite occluded.

Cyanosis may be occasioned by a patulous condition of the for-
amen ovale, or by some malformation, as, deficient ventricular
septum, constricted pulmonary artery, or any other abnormal con-
ditions of the heart or its bloodvessels; frequently, the foramen
ovale may continue open after birth, or it may re-open; and, any-
thing which interferes with the return of the blood to the heart,

CYANOSIS. 667

preventing the formation of arterial blood, may give rise to the
blue color observed in this disease.

The symptoms of cyanosis are a violet, blue, or purple color of
the surface of the body, especially the face, lips, hands, feet, and
genitals, and which color becomes increased by exertion or excite-
ment. In adition to this, indications of cardiac disease are pres-
ent, in a greater or less degree, as, paroxysms of dyspnoea of long
or short duration, palpitation, and sometimes syncope, diminished
temperature of the surface, and an extreme susceptibility to the
influence of cold, with a strong disposition to serous effusion.
The child is most commonly dull and sleepy, its respiration being
slow, and frequently labored, and eventually spasms and convul-
sions occur previous to the fatal termination. However, it must
be borne in mind, that perfect oxygenation of the blood is less
important to an infant than to an adult, and infants have, at times,
presented symptoms of imperfect oxygenation of the blood, with-
out any detrimental results.

Post-mortem examinations have, in the majority of deaths by
cyanosis, discovered some malformation of the heart, its bloodves-
sels, or of both. Meckel states, that " even when the foramen ovale
has remained open, there may be no cyanosis, if the pulmonary
artery is properly formed " — and Corvisart asserts, that " cyanosis
may be present when there is no communication between the
ventricles."

TREATMENT. — Although cures have been effected in this dis-
ease, yet we are not to anticipate such results as a general rule, and
especially if the infant be attacked with spasms or convulsions.

It is always proper to attend to the position of the child, as
recommended by Prof. Meigs, which is, to place it on its right side,
with the body inclined at an angle of 30°, the head being the high-
est part. On a moment's reflection it will be seen that the anatom-
ical, as well as the mechanical relations of the parts, indicate this
position, which maintains the left auricle perpendicularly above the
right, and the blood must thereby gradually pass into the pulmon-
ary ventricle, from the force of gravity alone. Yet, in cases
depending upon malformation, no benefit could result from this or
any other position.

In connection with this position, the child must not be allowed to
cry or worry, but should be kept as still as possible, and its body
should be occasionally bathed with tepid water. Should the natural
color of the skin return after several hours, with a freer respiration

668

AMERICAN ECLECTIC OBSTETRICS.

and a cessation of spasmodic action, all that will be necessary in the
way of medicine, is a gentle purgative, or two.

In many qases the disease terminates fatally in a few days, and,
sometimes, not until after several months ; the affected individual
seldom reaches the period of maturity. Whenever the disease does
not destroy the patient after a few weeks, there may possibly be
some benefit derived by treating him for a chronic disease of the
heart.

Sometimes, an infant will pass many hours after its birth with a
RETENTION OF URINE. This may be owing to the fact that
none has been secreted ; to an obstruction or debility of the parts
concerned in ejecting the urine; or, to some malformation, or closure
of the urethra. The first cause may be overcome by the exhibition
of mild diuretics, as, infusion of Marshmallow, Parsley root, Pump-
kin seed, or Watermelon seed. The second, by placing the child
for a short time in a warm bath, and then, after drying it, applying
pounded Garlic, or Onions over the region of the bladder. The
third cause will require a surgical operation for its removal, accord-
ing to the character of the difficulty.

A few days after birth, infants are attacked with a cutaneous
affection, called RED GUM (strophulus intertinetus). It is a slight
eruption of red, or sometimes whitish pimples, which are surrounded
by a reddish halo. This is probably occasioned by the exposure of
the surface to the action of the atmosphere, and other external
stimulating influences, as well as to changes effected in the capillary
circulation by the increased oxygenation of the blood. It is of no
importance and requires no especial treatment. The skin should be
frequently powdered with Arrowroot, and if there be any derange-
ment of the digestive functions, it may be remedied by a careful
exhibition of the compound Syrup of Rheum and Potassa. Nurses
are frequently in the habit of giving an infusion of Catnip and
Saffron, for this affection, and as no harm can be effected by it, a
prohibition would not always be prudent.

Infants are likewise liable to a yellowness of the eyes and skin,
shortly after birth, termed JAUNDICE ; and with this, the urine
may also be so colored with bile as to leave yellow stains upon the
diapers. Ordinarily, this is of but little consequence, and is gener-
ally treated by an infusion of Saffron and Catnip. But when the

FLATULENT COLIC. 669

stools denote biliary derangement, being whitish, clay-colored, or
whitish-yellow, it may be overcome by the exhibition of the com-
pound syrup of Rheum and Potassa, either with or without an infu-
sion of Leptandra Virginica. The surface should be kept clean by
daily bathing. Sometimes, however, in consequence of malforma-
tion, or disease of the liver or its ducts, a true jaundice may exist,
and which is apt to be pf a serious nature ; but this is not of very
frequent occurrence. ,

Shortly after birth, say on the second or third day, and some-
times later, infants are frequently attacked with OPHTHALMIA
{ophthalmia purulenta infantum, or oph. neonatorum). It commence-
with a redness and swelling of the lids, and, on awaking, the lids
will be observed to slightly stick together. Light occasions pains
and consequently the child keeps its eyes closed. At first, a little*
whitish matter will be observed lying on the inside of the lower
lid, and subsequently a profuse and constant discharge of thick,
yellow matter takes place, and which covers the whole eye. If
this be allowed to continue without attention, the child may
ultimately lose its eye. The treatment will consist in emollient
poultices to lessen inflammatory action, and a frequent bathing of
the eye with an infusion of Hydrastis Canadensis two parts, Gera-
nium Maculatum one part — mix. If a more stimulating applica-
tion is required, eight or ten grains of the sesquicarbonate of
Potassa may be added to a fluidounce of the infusion. The bowels
should be kept regular. Other local applications may also be used
with benefit, as the Borax lotion with Morphia, compouud lotion
of Golden Seal, compound Myrrh lotion, or compound Soda lotion.

Infants are frequently troubled with FLATULENT COLIC,
which may arise from costiveness, exposure to cold, from being
allowed to suckle too much, from irregularities in the diet of the
nurse, or some bad quality of her milk. It usually comes on sud-
denly, and may be known by the violent and incessant screaming
of the child, the hardness of the abdominal muscles, and the con-
stant agitation of the limbs, which are extended to their utmost,
and then immediately drawn up toward the abdomen, in rapid
succession.

The TREATMENT consists in giving a laxative and carmina-
tive injection, after which a warm infusion of Peppermint (or
Spearmint, should a suppression of urine be present), sweetened,

m

670 AMERICAN ECLECTIC OBSTETRICS.

and to which a very small quantity of supercarbonate of Soda has
been added, should be given, as an increased acidity of the stomach
is apt to be present; or, the compound syrup of Rheum and Potassa
may be substituted, when further action on the bowels is desired.
"When the attack is very severe, the bowels and back of the child
should be covered with flannels or fomentations, made as hot as
can be borne, and the child being held with its abdomen on the
nurse's knee, should be trotted for some time, while she gives a suc-
cession of light taps with her hand on its back, between the shoul-
der-blades and down to the small of its back. By this means,
I have frequently removed the most severe cases of colic, where
the child had been screaming incessantly for hours, and had taken
Paregoric, Godfrey's Cordial, hot Gin Sling, etc., without the least
benefit.

When an infant is subject to flatulent attacks, it may be over-
come by the administration of an infusion of Pleurisy root, Hops,
each two parts, Valerian, Scullcap, each, one part, Anise, three
parts, sweetened with molasses ; from ten to sixty drops may be
given for a dose. Godfrey's cordial, Paregoric, etc., are excessively
injurious, especially when used persistently for many days. An
attention to diet, cleanliness, the condition of the bowels, and exer-
cise, is always required, when the child is liable to a flatulent con-
dition of the alimentary tube.

CONSTIPATION", is common to some infants, and often proves
obstinate, being rather perpetuated by the administration of pur-
gatives. The introduction of a suppository of soap is, generally,
the best agent that can be used in ©rder to procure a stool ; two
evacuations should be obtained daily, at regular hours. And in
the interim, the following should be injected into the rectum, three
or four times daily, and retained within as long as possible, by
means of a compress, if necessary : Take of a strong infusion of
Hydrastis Canadensis, two fluidrachms, tincture of Prickly- Ash
berries, twenty or thirty minims; mix for an enema. This gives
tone and activity to the parts with which it comes in contact, and
also to neighboring parts by sympathetic action. Internally, in
very obstinate cases, an infusion of Leptandra Virginica, sweetened
with molasses, may be given in doses of from ten to sixty drops,
according to the child's age, and which should be repeated two
or three times a day, for a number of days, or even weeks, in suc-
cession.

N2EVUS MATERNI.

671

UMBILICAL HERNIA, may occur soon after birth, or a,
a later period. It may be occasioned by a large umbilicus, or,
from straining while crying, coughing, etc. It should always be
attended to at once. Place the child on its back, with the shoul-
ders slightly elevated, and the thighs flexed toward the abdomen.
Then carefully push the protruding tumor back, apply a compress
over it, and maintain it in place by a bandage. In some instances,
an umbilicus truss may be required, several kinds of which are in
use, but I prefer those manufactured by Mr. Marsh, of N. Y., or,
by Mr. W. L. Rees, of this city, surgical instrument maker, who
manufactures very available trusses for this and other forms of
hernia. The compress, above advised, may be made of linen,
folded several times, and moistened with some astringent ; or,
a piece of cork, may be cut of the proper size and shape, covered
with linen or soft leather, and applied. Adhesive inflammation,
sufficient to unite the parts, will take place in four or five days,
though the treatment should be continued for twelve or fourteen
days; and after this period has passed, the abdomen should be
properly supported by a bandage, for several months, in order to
prevent a return of the rupture ; and constipation should carefully
be guarded against by proper laxatives, etc.

EXCORIATION OP THE NAVEL, may be successfully
treated by washing the part twice a day with some Castile soap-
suds, and then dressing it with the red oxide of Lead plaster, or,
the compound Lead ointment. If there is a tendency to gangrene,
sulphate of Zinc, either in powder or solution, may be applied,
together with emollient poultices; and the strength of the system
should be kept up by tonics.

Sometimes, from a shrinking of the umbilical cord, or from its
being carelessly tied, the ligature will not press sufficiently on its
bloodvessels, and a HEMORRHAGE will take place. In such
cases, a second ligature must be applied below the original one,
and which should make the proper compression upon the vessels
without cutting the cord.
• Occasionally, at the time of the separation of the cord from the
navel, or a day or two subsequently, HEMORRHAGE FROM
THE UMBILICUS, will ensue, being frequently accompanied
with fungus growths. This difficulty may be overcome by the
application of sulphate of Zinc* either in powder or in solution
followed by the red oxide of Lead plaster, or, compound Lead

672

AMERICAN ECLECTIC OBSTETRICS.

ointment; and, if much inflammation be present, emollient poul-
tices should be applied.

N^EVUS MATERNT, or mother's marks, are frequently met
with ; they may exist on any part of the bod}', and present various
appearances, some being better supplied with blood than others.
When they are superficial, manifesting no tendency to spread, no
treatment is required, except to remove the disfiguration from the
face. When they are of the character of " aneurism by anasto-
mosis," having a tendency to spread or enlarge, to ulcerate, or to
bleed profusely, it is advisable to remove them when possible.

Various modes of TREATMENT have been recommended for
the removal of these marks, to which I will merely make a brief
reference; as, destruction of them by the application of platinum
wire, heated by galvanism; the injection of a small quantity of
the solution of perchloride of Iron into various parts of the
nsevus; the application of the ligature to some varieties; the
application of intense cold over the part; and, in the subcutaneous
form, it has been removed by vaccinating in the mark. The appli-
cation of powdered sulphate of Zinc over the nsevus, repeated
daily, and continued until it is destroyed, then facilitating the
removal of the slough by an Elm poultice, and subsequently treat-
ing the ulcer with the compound Lead ointment, has succeeded in
several instances in affecting a cure, even in cases where the nsevus
assumed a malignant appearance. If not removed after the
slough has passed off, renew the application of the Zinc, and follow
by the same treatment as above.

Infants are occasionally troubled with a condition, known as
being TONGUE-TIED. This arises from the frsenum linguse, or
bridle under the tongue, being so short, or attached so far forward
as to interfere with the motions of the tongue in sucking, as well
as in speaking, when further advanced in years; occasionally, it is
owing to the presence of a false membrane. If the infant can
protrude the tip of the tongue beyond the lips, or can suck well,
no interference is demanded, for there is no difficulty of the kind.
It is of very rare occurrence.

The TREATMENT consists in cutting the frsenum, so as to
loosen the tongue from its attachment. The best time for opera-
ting is when the infant sleeps; the tongue may then be held up
with the index or forefinger of one hand, while with the other,

HARE -LIP.

673

holding a pair of blunt scissors, and having its points directed
downward and as near the floor of the mouth as possible, cut loose
about one-eighth of an inch of the anterior portion of the mem-
brane— and which will be followed by only a few drops of blood
which must be wiped out. Care must be taken not to cut the
lingual artery, which is situated on the inferior surface of the
tongue; and, should it be imprudently cut, the hemorrhage must
be checked by compression, or the actual cautery. If too exten-
sive a cut be made, the child may swallow its tongue, which,
however, may be returned, bypassing a spoon dipped in molasses
or syrup down to the point or edges of the organ, and bringing
it back.

HYDROCELE, is sometimes met with in infants, and is gener-
ally removed by the application of compresses moistened with a
solution of Muriate of Ammonia. It is rare that a puncture will
be required.

Infants, soon after birth, are sometimes troubled with a SWELL-
ING AND HARDNESS OF THE BREASTS, which may be
owing to cold, blows, bruises, or, an excited condition of the parts.
It may be overcome by gentle frictions with Olive oil and tincture
of Camphor applied two or three times a day, employing in the
intervals fomentations of Mullen leaves and blossoms, or, of
the flowers of St. Johnswort; if there is much inflammation, poul-
tice of Elm and Lobelia may be applied. Occasionally, and
especially if neglected, or improperly treated, sloughing will take
place ; this may be treated by stimulating washes, and the Red
Oxide of Lead Plaster, in conjunction with tonics internally, when
there is much debility.

HARE-LIP, is an imperfection often met with after birth. It is
a perpendicular or oblique division of the upper lip, either imme-
diately under the septum of the nose, or under one of the nostrils.
Double hare-lip is when there are two divisions. Sometimes the
fissure extends back through the palate bone, as well as through the
soft palate, in which case, an operation has sometimes been per-
formed, which may be found described in surgical works.

In ordinary cases of hare-lip the deformity is removed by a sim-
ple operation ; and, on account of the tendency to convulsions in
very young children, after the operation, it is better to wait until

674

AMERICAN ECLECTIC OBSTETRICS.

they are at least two or three weeks old ; a year or two is still
better, if the child can suck, or be safely fed in the meantime.

The operation is performed, by removing the edges of the fissure
with a scalpel, or bistoury, cutting upon the part while a flat piece
of wood is held between the lip and the gum ; some prefer incising
the edges with a pair of long-handled, sharp scissors, made for the
purpose. Should the gum and lip be adherent, they must be sepa-
rated by the knife ; and when the frenulum is in the way of the
operation, it must be divided. The incision, by whatever instru-
ment it is effected, should be as smooth and even as possible, that
the edges may readily unite by the first intention.

The fissure, now resembling the inverted letter a, is to be closed,
bringing the edges together, through which three flat needles are
to be passed. It is better to have gilt needles with movable steel
points, on account of the steel needles being liable to rust, and they
should be oiled before introducing them. The first needle should
be introduced through and across the wound at its inferior or
lower termination ; it should penetrate sufficiently deep, say about
two-thirds through the substance of the lip, to keep the cut surfaces
in approximation, but should not pass through the inner surface of
the lip. One or two other needles are then to be passed similarly,
at equidistant points from the first needle, being thrust, as before,
sufficiently deep to almost reach the inner mucous lining of the lip.
A ligature, or common waxed thread, is to be repeatedly wound round
the ends of the pins, forming a twisted suture, so as to keep the
outer surface of the wound in close contact, being careful, however,
not to apply it so tightly as to occasion a subsequent sloughing of
the parts. Should high inflammatory action supervene, it may be
reduced by the application of cold water ; and any tendency to cer-
ebral irritation, or sympathetic fever, should be at once removed
by appropriate means.

The child should be kept in a room, away from any excitement
which would occasion crying or laughing, and even talking when
old enough, and must be fed with a spoon, the diet being entirely
of a fluid character. And should there be any danger of a disar-
rangement of the parts, the cheeks may be pressed forward, and
then a long strip of adhesive plaster, reaching from ear to ear, may
be applied between these points and over the lip.

After four, five, or six days, the needles may be removed, and
strips of adhesive plaster applied, which will be sufficient to hold
the parts together. In removing the needles, loosen them gradu-

APHTHiE.

675

ally, with the forceps, as any sudden jerks, or forcible pulling,
would be apt to separate, or otherwise injure the wound. If there
be a double hare-lip, it will be better to complete the operation by
incising and ligaturing both fissures at the same time.

CHAPTER LII.

APHTHAE, THRUSH TRISMUS NASCENTIUM — PORRIGO LARVALIS, MILK SCAB.

Infants are subject to an inflammation of the mouth, called
APHTHAE, Thrush, or Stomatite Folliculeuse, the symptoms of
which vary according to the severity of the attack. Upon an
examination, the tongue, lips, and interior surface of the mouth
and throat, will be found more or less covered with small, white
flakes, or pearl-colored vesicles, which proceed to superficial ulcer-
ation, and terminate by an exfoliation of white crusts. These
vesicles may be distinct, or confluent, and in the more severe forms,
are accompanied with so much pain that the child can not suck,
its mouth is hot, its lips frequently swollen, with a dribbling of
saliva. The breath is usually disagreeable and of an acid odor,
the pulse quick and feeble, bowels deranged, frequent vomiting,
and a diarrhea with green or watery evacuations, and exeoriated
anus. The disease may extend to the pharynx, and trachea, and,
in very severe cases, it is continued through the alimentary canal
to the anus. The child becomes pale, restless, and fretful, rapidly
emaciating, and presenting a countenance indicative of much dis-
tress. When mild, but few of these symptoms are manifested;
but when very severe, there may also be cephalic disturbance,
severe abdominal pain, diarrhea, and typhoid symptoms, under
which the little patient will rapidly sink. Occasionally the ulcers
assume a gangrenous condition.

Weakly and unhealthy children, as well as those raised by hand,
are more subject to this disease than others; it may also be
induced by improper food, uncleanliness, unhealthy air, and not
unfrequently occurs as a secondary affection to other diseases.

It is sometimes mistaken for a disease occasionally met with,
called White Thrush, or Muguet, but may be distinguished, by
remembering that this latter affection presents no ulceration, being

/

676

AMERICAN ECLECTIC OBSTETRICS.

a deposition of curdy matter or false membrane upon the epithe-
lium, without involving the destruction of the adjacent membrane;
while in true Thrush, the follicular points of the tongue enlarge,
without losing their circular form, and from their central orifices a
whitish matter escapes, being accompanied by ulceration. The
ulcer has rounded edges, is more or less tumefied, and is invariably
surrounded by an inflamed red circle.

In the mild form, the white crusts fall off, and in a few days the
ulcers heal. But when the aphthae are confluent, with extensive
ulceration, vomiting, and diarrhea, or when the crusts, instead of
being white, are of a dark color, with an unhealthy appearance of
the ulcers, the pulse being quick and feeble, with rapid emaciation,
the prognosis is very unfavorable.

TREATMENT. — In the milder forms of this disease little or no
treatment is necessary, but in the severe forms it is indispensable.
The treatment should be commenced by the administration of/ the
compound syrup of Rhubarb and Potassa, in laxative doses, for
the purpose of removing any morbid accumulations which may
exist in the alimentary tube, to neutralize any exrsting abnormal
acidity, to aid in the expulsion of flatus, which is common to the
disease, and especially to exert a normal influence on the hepatic
and digestive functions. After and during the action of the laxa-
tive— which should be exhibited daily, at least for a few days — two
or three drops of the tincture of chloride of Iron should be given
in a sufficient quantity of infusion of Hydrastis Canadensis, and
this may be repeated every two, three, or four hours, according to
the severity of the disease. I have heretofore made a brief
reference to the action of this chalybeate, so that it will be
unnecessary here.

The mouth should be frequently but lightly washed with a strong
infusion of equal parts of Hydrastis Canadensis and Caulophyllum
Thalictroides, to which some Honey and a small portion of Borax
have been added; and a portion of this may be occasionally
swallowed, especially in the severe cases, with advantage. Care
must be employed not to irritate the mouth by rough swabbing, or
by forcing off the white flakes or deadened epithelium, as either
of these may augment the severity of the disease. There are other
agents which may be used with advantage as local applications;
thus, an infusion of Ligustrum Yulgare, or Hamamelis Virginica,
a solution of Alum, or Nitrate of Silver, etc. ; but I prefer the
above, which I have employed with much success for the last

APTII^l.

677

twenty -seven years, always administering some of it internally.
Chlorate of Potassa internally, and applied locally, in solution, has
been found a very efficacious remedy in most cases. I have used
it in a few cases, and with advantage.

When vomiting occurs, an infusion of burnt bread or parched
corn will have a tendency to check it; and if the irritation has
extended into the stomach or alimentary canal, Salad oil may be
used with benefit, in small doses. Perhaps Cod-liver oil, or Cocoa-
nut oil, might be useful in some cases. When the ulcers assume a
dark or brown hue, or exhibit a gangrenous tendency, equal parts
of Salad oil, Yeast, and Spirits of Nitric Ether, may be given in
doses suited to the child's age, and which should be repeated at
proper intervals. In addition to this, the system should be sup-
ported by Quinia and cordials, as wine-whey, milk and wine,
chicken-broth and wine, etc. Sometimes the Iodide of Potassium,
combined with some alterative, will be found valuable, especially
in children of scrofulous parents.

When there is excoriation of the anus, it should be frequently
and gently bathed with warm water, dried carefully, and then
sprinkled with equal parts of Lapis Caliminaris and finely pow-
dered Elm Bark.

The body of the child should be kept clean, frequently bathing
it with warm water, or a weak alkaline solution; and if it be much
debilitated, brandy or some other stimulant may be added to the
solution. Attention should be paid to the condition of the
mother's health, who must be placed under treatment if necessary:
her diet must invariably be regulated, as well as the condition of
the bowels, exercise, etc. It not unfrequently occurs, that a change
of tbe nurse, or weaning the child and feeding it cow's milk,
arrowroot, barley-water, etc., will be followed by a disappearance
of all the symptoms; shortly after which, if the mother's milk has
not been allowed to "dry up," it may be safely restored to its
natural food.

The Persesquinitrate of Iron has been highly recommended in
this affection. Take of solution of Persesquinitrate of Iron forty
drops, syrup of Orange Peel half a fluidounce, Water five and a
half fluidounces; mix, and give one-fourth for a dose to a child
three or four years old, repeating it four times a day.

Recent microscopic investigations are stated to have discovered
that the disease depends upon a vegetable parasitic growth, and
may be cured by the local application and internal administration

678

AMERICAN ECLECTIC OBSTETRICS.

of a solution of Hyposulphate of Soda in some bitter tonic infusion.
I have recently employed this solution internally, together with a
solution of Perchloride of Iron locally, to the aphtha, with marked
benefit; in some instances, solution of chlorate of Potassa may be
substituted for that of the ferruginous perchloride.

TRISMUS NASCENTIUM, or NINE-DAY FITS, is a disease
which seldom occurs in private practice, and which has heretofore
most commonly proved fatal. It is peculiar to hot climates, and is
more frequently met with among the infants of the white and black
laboring classes.

The causes of this affection are very little understood, and have
given rise to much speculation : it has been attributed to consti-
pation, to vitiated air, to uncleanliness, to intoxication and irregu-
larity of diet in the nurse, etc. More recently attention has been
called by Dr. Sims to pressure upon the brain by the occipital bone,
as a cause, and which is occasioned by the child's being allowed to
lie for a long time upon its back, as has been the case with slaves, and
those who, being compelled to labor, can not bestow the necessary
attentions upon their infants : in this dorsal decubitus the occiput
is made to pass under the parietal bones, and compress the brain to
a greater or less degree. Dr. Sims adduces many cases in support
of his theory, in which a mere change of position effected cures.

Colles, Billard, and several others, attribute the disease to inflam-
mation and ulceration of the umbilicus, and instances are brought
forth in which the traumatico-tetanic condition of the umbilicus
appeared to be the exciting cause.

The affection is of a tetanic character; and as the infantile ner-
vous system is extremely susceptible to impressions, it is very
probable that various exciting causes may have produced the mal-
ady, among which the last two named may be the most common.

The attack usually manifests itself on the eighth or ninth day
after the division of the funis. The precursory symptoms are thus
given by Dr. J. Clarke : " A livid circle around the eyes, sudden
changes of color, a twisting of the limbs without cause when
awake, screwing up the lips like a purse, involuntary smiling, with
a peculiar kind of screech ; the child is greedy, and the bowels
easily moved, with natural, greenish, slimy, or knotty evacuations.

" With one or more of the symptoms, and sometimes without
any warning whatever, the child is seized with violent irregular
contractions and relaxations of its muscular frame, particularly

TRISMUS NASCENTIUM.

679

those of the face and extremities. These convulsive motions recur
at uncertain intervals and produce various effects. In some the
agitation is very great ; the mouth foams ; the thumbs are riveted
in the palms of the hands ; the jaws are locked from the commence-
ment, so as to prevent the action of sucking or swallowing; and
any attempts to wet the mouth or fauces, or to administer medi-
cines, seem to aggravate the spasms very much : the face becomes
turgid and of a livid hue, as well as other parts of the body; and
in from eight to forty hours the child dies."— {Churchill.)

TREATMENT. — It will be well to ascertain the condition of
the occiput, whether it has passed under the parietal bones, and is
compressing that portion of the brain, and also whether the infant
has been lying continuously upon its back ; if such be the case, its
position must be changed from the back to the side, and on the
right side will be the best. Attention should also be directed to
the condition of the umbilicus, if it be ulcerated or inflamed ; or
if, on pressure, pain is manifested by the movements of the child
a poultice of Elm and Lobelia should be applied, and which must
be changed three or four times a day. If a gangrenous condition
of the umbilicus is observed, a solution of Sulphate of Zinc, half
a drachm or a drachm of the salt to afluidounce of water, should
be applied, and its use persevered in until healthy granulations
make their appearance ; the solution may be applied on lint, and
should be covered with the above poultice.

The child should be kept clean and dry, removing it if necessary,
to a purer atmosphere ; keeping its bowels regular by the compound
syrup of Rhubarb and Potassa ; applying moderately cold water
to the head ; and bathing along the whole spinal column and infe-
rior extremities with the compound liniment of Oil of Amber,
which may be repeated two or three times a day. An infusion of
equal parts of Symplocarpus Fcetidus, Cypripedium Pubescens,
and Scutellaria Lateriflora, should be given every hour or two,
either by mouth or by injection, and to each dose of which from
five to ten drops of the compound tincture of Lobelia and Capsi-
cum may be added.

Among the several cutaneous diseases to which infants are lia-
ble, is one known as milk scall, or milk scab, and which has been
variously termed by writers, thus, Porrigo Larvalis, Crusta Lactea,
Porrigo Favosa, Tinea Lactea, etc. The disease is usually first
observed upon the forehead and cheeks, and consists in an eruption

680

AMERICAN ECLECTIC OBSTETRICS.

of minute superficial pustules, of a yellowish white color, united in
groups on a red surface, and more or less confluent. It sometimes
attacks the hands, feet, and other parts of the body, and has like-
wise been observed in adults. The pustules will at first be found
to contain a transparent fluid, which soon becomes yellowish-white
and opaque, and being discharged, concretes into thin, yellowish,
or greenish crusts. As the pustular patches spread, there is a
renewal of the discharge, which likewise continues from beneath
the crusts, increasing their thickness and extent. The eruption
is subject to various modifications — sometimes the discharge is
scarcely perceptible, with a dry and brown scab covering the sur-
face; at other times, the discharge is profuse, with a red and exco-
riated surface. Occasional^, the whole face, with the exception
of the nose and eyelids, is covered like a mask, with a large, thick
crust, formed of numerous smaller ones, and, almost invariably,
the disease is accompanied with intense itching, and more or less
pain. "When the disease is about terminating, the discharge grad-
ually ceases, the crusts fall off and are not renewed, the surface
under them, at first elevated, red, and tender, gradually lessens in
color, slight desquamation ensues, and the skin slowly returns to
its normal condition without any disfiguration, unless the child has
been allowed to tear its cheeks by scratching.

The duration of the disease is variable, and it is not uncommon
for it to remain several months before disappearing. It rarely
remains beyond the period of teething, and hence, in obstinate
cases, means should be employed to allay the itching, that the face
may not be marked by the nails of the child. It does not appear
to be contagious ; and its causes are involved in much obscurity.

TREATMENT. — I have, within the last five or six years, been
called to treat quite a number of cases of this disease; at first, I
was not successful, but have recently found the following means to
be efficacious :

If there is any derangement of the digestive or hepatic func-
tions, administer laxative doses, every day or two, of the com-
pound syrup of Rhubarb and Potassa. Give daily, three times a
day, from five to ten or fifteen drops of the following preparation,
according to the age of the child : Take of saturated tincture of
Cimicifuga, saturated tincture of Ptelea Trifoliata, equal parts;
mix. Administer this in some sweetened water, adding to each
dose from one to three drops of the tincture of chloride of Iron.
The diet of the child should be regulated as to quantity, and the

CORYZA.

681

periods of feeding; in several cases, the disease proved unyielding
until the child was given to another nurse, when it rapidly disap-
peared. As a local application, I know of none equal to the fol-
lowing: Take some fresh leaves of the Viola Tricolor, known by
the various names of Tricolored Violet, Heartsease, Herb Trinity,
Pansey, etc., add these to some good cream, and simmer together
until an ointment is made, strongly impregnated with the virtues
of the leaves. To one ounce of this ointment add three drachms
of Sweet Gum (Liquidum Liquidambar Styracifluoe), and mix to-
gether by means of heat. Th face should be lightly washed with
Castile soapsuds, carefully and gently dried, and the ointment
applied; and this should be repeated two or three times daily.
This ointment will also be found very useful in many other cutane-
ous maladies, and it is somewhat singular tbat our practitioners
pay but little attention to the collection and employment of so
efficient an article as the Sweet Gum. Tallow may be substituted
for the cream, and Liquid Storax for the Sweet Gum, but they will
form an inferior compound.

The child should be exercised freely by its attendant, and be
exposed as much as possible to the open atmosphere.

For the last twTenty years I have met with extraordinary success
in the treatment of cutaneous cancer, scald-head, barber's-itch, and
various other diseases of the skin, by the application of a solution
of Oxalic Acid, of greater or less strength; and, more recently,
those of my colleagues, and others in the profession, to whom I
have made its virtues known, have employed it in similar diseases,
and with like results. I have no doubt that this agent would
prove very efficacious in the disease under consideration, but, at
the same time, I should hesitate to employ it on infants for fear of
some serious results. Probably, a solution of Citric Acid might
answer as a useful and a much safer remedy. The formula for
oxalic acid is C2 03=36; that for citric acid is C12 H5 011=165.

CORYZA, Nasal Catarrh, or Snuffles, is a very common and
troublesome disease among infants. It is an affection of the nasal
mucous membrane and air passages of the head, and generally
commences by frequent sneezing; at first there is little discharge
from the nostrils, but in a short time, a thin mucous secretion
takes place, which finally becomes profuse, and of a thick, muco-
purulent character. 'Not unfrequently, the discharge is acrid and
irritating. The mucus fills the passages, forming a very trouble-
44

682

AMERICAN ECLECTIC OBSTETRICS

some obstruction, causing the child to make a snuffling or rattling
sound in breathing through the nose, and interfering with its free
respiration while sucking. The eyes are more or less suffused,
watery, and sensitive to light, and the thirst is increased, with
some slight febrile disturbance. Sometimes, especially when the
disease appears epidemically, the symptoms are much more severe,
with great constitutional debility. After the third or fourth day
the symptoms usually diminish, but, and especially when not
under treatment, or in the severe forms, it may continue for sev-
eral weeks.

Coryza is usually produced by cold; at times it prevails as an
epidemic; and it is frequently found accompanying other diseases,
as the exanthemata. Usually the disease requires but little treat-
ment, but in its severe forms, it must be watched, as the child may
die from the obstruction preventing free access of atmospheric air
to the lungs.

TREATMENT. — In the mild forms, a gentle purgative, warm
baths, with warm diaphoretic drinks, will be found sufficient;
with, perhaps, a warm fomentation to the nose and forehead, or,
what I consider still better, an application of goose-grease, or
tallow. This greasing of the nose and forehead externally, is a
common practice with nurses, and I have found it decidedly bene-
ficial; and, notwithstanding many of our eminent practitioners
treat with disdain the simple measures advised by old nurses, it is
well to remember that they are more observing of, and have better
opportunities to ascertain, the influence of agents upon children
than physicians, who seldom remain with a patient to exceed
fifteen minutes at a visit; and he who will listen to, and watch
the opinions and methods adopted by them, especially in the man-
agement of infants, can never fail to derive some useful and valu-
able suggestions.

In the severe forms of this disease, it may be proper to com-
mence the treatment by an emetic, for which purpose I prefer the
compound tincture of Lobelia. The emetic should be followed
by a mild purgative, after which moderate diaphoresis should be
produced and maintained by some warm drinks, aided, in some
instances, by the compound tincture of Virginia Snakeroot. To
relieve the nasal obstruction, and lessen the inflammation of the
mucous membrane, the compound tincture of Grolden Seal, either
pure or diluted, should be frequently introduced into each nostril,
as far as necessary, by means of a camel' s-hair pencil.

CORYZA.

683

When the disease occurs as an epidemic, a solution of sulphate
of Quinia may be administered, together with an infusion of
Hydrastis Canadensis and Cimicifuga Racemosa.

When the nose is much obstructed, the infant should be taken
from the breast for a few days, and be fed at regular intervals, two
or three times a day. Children of advanced age should be kept
on a low diet during the first stage of the disease. The surface
should be bathed with warm water daily, the body should be kept
properly warmed, and a flannel cap should be worn, not only dur-
ing the disease, but for some days after its cure.

PAET VI..
OBSTETRIC MATERIA MEDIC A.

\

Since having prepared the previous pages of this volume, it has been suggested to
me by many medical friends, to add a list of agents more especially adapted to obstet-
ric practice, in order that the student may at once refer to them, without being obliged
to resort to another book. The idea appears to me a useful one, and I will, therefore,
close the present work by presenting a very brief account of such remedies as will
prove serviceable to the obstetrician. For a thorough description of the articles selected,
and their uses in other departments of medical practice, the student is referred to
the author's American Dispensatory.

ACHILLEA MILLEFOLIUM.

TARROW.

This is an American perennial herb, which may be used in the form of infusion,
tincture, or fluid-extract. It has been successfully employed in infusion, in diarrhea
during pregnancy, and at the time of, or shortly after parturition. In menorrhagia,
the saturated tincture in half fluidounce doses, repeated three or four times a day, has
been found beneficial. The infusion has been used with advantage, as a vaginal injec-
tion in leucorrhea. The dose of the infusion is from four to six fluidounces three or
four times a day, and any unpleasantness of flavor may be removed by the addition of
a few drops of essence of Cinnamon. The dose of the fluid-extract is one fluidrachm.
The volatile oil, or its tincture, may likewise be used in doses of from ten to thirty
drops, and its disagreeable taste may be concealed by a few drops of Oil of Anise, or
Oil of Cinnamon.

ACIDUM GALLICUM.

GALLIC ACID.

This acid is generally prepared from Galls; it is a powerful astringent, effecting its
influence without causing constipation. It has been given with benefit in menorrha-

MATERIA MEDICA.

685

gia, uterine hemorrhage and chronic diarrhea. The dose is from five to ten or fifteen
grains, three or four times a clay. In irritable and painful conditions it may be
advantageously combined with Opium.

ACIDUM TANNICUM.

TANNIC ACID.

Tannic acid is likewise prepared from Galls ; it is a pure astringent, but occasions
constipation. It will be found useful in diarrhea, and all passive discharges from the
uterus; and as a local application in aphthous ulceration of the mouth, sore nipples,
and prolapsus ani of infants. When used losally it may be employed in solution or
ointment, in the proportion of five grains of the Acid to a fluidounce of Water, or to
four scruples of Lard. Tannic acid is given in doses of from one grain to five.

ACONITUM NAPELLUS.

MONKSHOOD.

This is a European perennial herb, which may be used in several forms, but those of
the saturated tincture of of the root, and the alcholic extract, are preferred. It should
always be given in small doses; in large ones it acts as an energetic acro-narcotic
poison. It exerts a remarkable influence over febrile and inflammatory affections, and
has a decided tendency to relieve pain. Three parts of the tincture of Gelseminum
combined with one part of tincture of Aconite root, and administered in doses of ten
or twenty drops, every hour or two, or oftener if required, will be found very beneficial
in those instances where it is desirable to overcome uterine irritability during parturi-
tion, check its powerful contractions and lessen the pain. The same combination will
likewise prove efficacious in the treatment of puerperal fever, and other febrile or
inflammatory conditions during the parturient period. In painful dysmenorrhea,
where large doses of tincture of Gelseminum have been required before relief was
obtained, I have met with the most excellent results from its combination, as above
with the tincture of Aconite root; and in this distressing affection I would particularly
invite the attention of practitioners to the remedy, as I consider it almost a specific.
Neuralgia, or rheumatism of the uterus, may be removed by the same preparation;
some practitioners administer from three to five grains of sulphate of Quinia in con-
junction with the tincture, whenever there are marked symptoms of periodicity.
Sometimes the substitution of the tincture of Cimicifuga, for that of the Gelseminum,
will answer a much better purpose. Some females are subject to an annoying species
of false pains, near the time of parturition, which frequently render them excessively
impatient and irritable; these pains are not palliated by an alvine evacuation, but
may be promptly removed by either of the above preparations. When Aconite is
administered in poisonous doses, the stomach should be immediately and thoroughly
evacuated, and stimulants employed both internally and externally. The dose of the
tincture m the root is from three to ten drops in a teaspoonful of water; it is better
to commence with the smaller dose, and gradually increase it. The extract may be
given in doses of one-sixth of a grain two or three times a day, and gradually
increased to half a grain, or a grain.

686

AMERICAN ECLECTIC OBSTETRICS.

ALETRIS FARINOSA.

UNICORN-ROOT.

A perennial herb, common to the United States, the root of which exerts a tonic or
stimulating influence upon the reproductive organs of the female. In amenorrhea,
dysmenorrhea, and engorged conditions of the uterus, it will be found of especial ben-
efit, removing the difficulties by restoring the uterus to its normal energy, when a defi-
ciency of this occasions the malady ; it will also be found advantageous in those
instances where there is an habitual tendency to abort, not depending upon syphilitic
taint, or other causes independent of the condition of the reproductive organs. I have
found it useful in prolapsus uteri, and am inclined to believe that it exerts a peculiar
influence upon the uterine ligaments, having cured several severe cases of uterine pro-
lapsus by this agent alone, without the aid of any mechanical means. In prolapsus I
most usually combine it with equal parts of Pleurisy-root and black Cohosh, and which
may be given in powder, or tincture, or medicated wine; or the concentrated prepara-
tions of these articles may be used.

The alcoholic extract, called Aletridin, may be used in affections of the uterus, with
much advantage, its dose being one or two grains, to be repeated three or. four times
daily. This is another exceedingly valuable agent that is too much ^neglected by our
practitioners. Its combination with Asclepidin, Senecin, Caulophyllin, or Cimicifugin,
will frequently be found useful. The dose of the root in powder 7is from five to ten
grains, three or four times a day; of the saturated tincture, from five to twenty drop?,
in wine, or water.

ALOE SOCOTRINA.

ALOES.

There are several varieties of this article, the best among which is the Socotrine
Aloes, derived from the leaves of the' plant, growing on the island of Socotra. It is
most commonly used on account,of its purgative or laxative properties; but, independ-
ent of this, it exerts an influence upon the uterus, either directly, or, by sympathetic-
extension of the intestinal irritability which it usually produces, and which has fre-
quently been beneficial in amenorrhea. It is generally administered in the form
known as tincture of Aloes and Myrrh, or elixir proprietatis, and which is prepared as
follows:

5:. Powdered Aloes, three ounces,
Saffron, two ounces,
Tincture of Myrrh, two pints. Mix.

Macerate the mixture for fourteen days, and filter. The dose is one or two flui-
drachms.

The following powder has proved efficacious in amenorrhea, depending principally
upon a derangement or torpid condition of the uterine functions:
fy. Powdered Aloes, fifteen grains,
Extract of Savin, two scruples,
Powdered Ipecacuanha, one scruple.

Mix, and divide into twenty powders, of which one may be given for a dose, and
repeated three times daily.

A practitioner has furnished me with a formula for a pill, which he assures me, he
has invariably found to restore menstruation in all cases of amenorrhea. It may be
a very good pill for aught I know, but it contains too many articles, so that it is impos-

MATERIA MEDICA.

687

Bible to determine on which agent the benefit, if any there be, depends; or, whether it
is a compatible mixture. I trust the time may speedily arrive, when such heteroge-
neous mixtures will be banished from our pharmacy, and when all classes of practi-
tioners will trust more to the administration of simple medicines, and the determina-
tion of their therapeutical powers. I iusert the formula as a matter of curiosity.

I£. Powdered Aloes,

Dried sulphate of Iron,

Powdered Myrrh, of each, half a drachm,

Cimicifugin,

Iodide of Potassium, of each, one scruple,
Oil of Savin, twenty drops,

Extract of Water-Pepper, a sufficient quantity to form the whole into
a pill-mass. Mix.

Divide the mass into forty-eight pills, of which two are to be taken for a dose, and
repeated three times a day.

Aloes is contra-indicated in inflammatory conditions, as gastritis, enteritis, perito-
nitis, etc., in irritable plethoric habits, in persons subject to piles, during pregnancy,
and among females subject to sudden evacuations from the uterus. The dose of Aloes,
is from five to twenty grains, and it is more generally administered in the form of pill.

ALTELEA OFFICINALIS.

MARSHM ALLOW.

A perennial herb common to several parts of Europe and this country. Its principal
employment is as a diuretic, in the form of infusion, either alone, or in combination
with some other diuretic, as Spearmint, Hair-Cap Moss, etc. It may be used in all
febrile or inflammatory affections, plethoric conditions, and other difficulties where
a mucilaginous diuretic is indicated. The Hibiscus Palustris, Marsh Hibiscus common
to this country, has similar properties, and may be used as a substitute.

AMARANTHUS HYPOCIIONDRIACUS.

AMARANTH.

A plant common to the Middle States, and known also by the name of Red Cocks-
comb. It possesses an astringent influence, and has been found of service in the diar-
rhea of parturient women, in menorrhagia, and as a local application in aphthous
ulceration of the mouth. It is used in decoction, which may be taken freely.

AMMONIA HYDROCHLORAS.

CHLORO-HYDRATE OF AMMONIA.

Also known as Muriate of Ammonia, or Sal- Ammoniac. This salt is laxative, diuretic, "
diaphoretic, or refrigerant, according to the quantity and mode of administration; it
is also considered a stimulating alterative, influencing the mucous, serous, and fibrous
tissues. This property is owing to its solvent power, which it possesses in an uncom-

/

688

AMERICAN ECLECTIC OBSTETRICS.

mon degree, breaking down the tissues of the system more rapidly than mercury, and
without any of its deleterious effects. In consequence of this action it will be found
very beneficial in several chronic uterine • affect ions. Induration of the uterus,
engorgement, and ulceration of the cervix, have promptly yielded to its influence. It
may be given in combination with Podophyllin, Caulophyllin, Cimicifugin, Alctridrin,
etc., according to indications.

The best mode of administering Muriate of Ammonia is in powder, or solution in
syrup; the dose is from five to thirty grains, every three or four hours. As an injec-
tion in leucorrhea, engorgement, or excoriation of the cervix, it may be used in a solu-
tion containing about three or four drachms of the salt to a pint of rain-water. This
is a remedial agent the beneficial influences of which are not sufficiently recognized
by the profession.

ANTHEMIS NOBILIS.

CHAMOMILE.

This herb is a native of Europe, the flowers of which are the officinal portion.
Chamomile flowers are tonic in small doses, and emetic in large. Independent of these
properties, however, they exert an emmenagogue influence, on which account they are
very useful in amenorrhea, and likewise in suspended lochia. They may be given in
infusion, cold, one or two fluidounces every three or four hours; or, a saturated tinc-
ture may be exhibited in one or two fluidrachm doses, at the same intervals. After an
abortion, it frequently happens that the uterus does not firmly contract, the cervix will
be found soft, and the os uteri considerably open, with move or less discharge of a san-
guineous character, in addition to which, the female will complain of great debility,
and nervousness, being subject to attacks of hysteria; in such cases I have found
prompt relief to follow the administration of a cold infusion of Chamomile flowers, in
doses of two fluidounces, to be repeated three or four times a day, and to each dose of
which were added twenty drops of Sulphuric Ether. The oil of Chamomile, in doses of
from five to fifteen drops on Sugar, has afforded almost immediate relief in those
instances of dysmenorrhea where the pain disappears on the appearance of the
catamenia.

APIUM PETROSELINUM.

PARSLEY.

A well-known plant, native of Europe, but extensively cultivated for culinary pur-
poses. The root is diuretic, and may be used in retention of urine, scalding of urine,
strangury, and whenever diuresis is desired; it is most commonly administered in
infusion. The fresh leaves, when bruised, form an excellent application to swelled
breasts, and "dry up the milk" of wet nurses; they have been combined with the,
ointment on page 655, for this purpose.

APOCYNUM CANNABINUM.

INDIAN HEMP.

A plant common to this country, the root of which is officinal. It is a hydragogue-
oathartic, and diuretic, and has been used in dropsy, and some febrile affections. A

MATERIA MEDICA.

689

strong decoction of equal parts of Indian Hemp, and Pleurisy-root, given in fluidrachm
doses, every one, two, or three hours, will be found exceedingly valuable in irritable
and congested uterus, accompanied with nausea, vomiting, tympanitic abdomen, head-
ache, and powerful pulsations of the abdominal aorta. Or, the fluid .extracts of the
two articles may be combined. The alcoholic extract of Indian Hemp will be found
a useful preparation.

ARGENTI NITRAS.

NITRATE OF SILVER.

This salt is employed as a local application to ulcerations, granulations, and excori-
ations of the cervix, likewise to syphilitic eruptions or ulcers of the vagina, and in
leucorrhea. The solid stick is used, or a solution varying in strength from five grains
to eighty of the salt, to a fluidounec of distilled water. When the pain resulting from
its application is excessive, it may be promptly relieved by washing the parts with a
solution of common Salt, which, by decomposition, converts it into the insoluble Chlo-
ride of Silver. Recently, Mr. S. Wells has introduced the use of Nitrate of Silver in
the solid form, diluted by a mixture of one, two, or three parts of Nitrate of Potassa ;
the two salts are melted together, poured into molds, and allowed to cool. By this
means the caustic may be applied of any desired strength, and its effect be limited to
the exact seat of morbid action. '

ARISTOLOCHIA SERPENTARIA.

YIRGI3fcLA SNAKEROOT.

This plant is common to the southern and central portions of the United States; the
root is the officinal part, and is stated to have been efficacious, when exhibited in infu-
sion, in amenorrhea. It is introduced here on account of the preparation, which is
named the Compound Tincture of Virginia Snakeroot, and which is prepared as
follows :

Virginia Snakeroot,
Ipecacuanha,
Saffron,
Camphor,

Opium, of each, in powder, or bruised, two ounces,
Holland Gin, or,

Diluted Alcohol, six pints. Mix.
Macerate for fourteen days, express, and filter through paper.

This preparation is a powerful sudorific, and will be found efficacious in all cases
where it is desired to produce copious perspiration, lessen pain, allay nervous irrita-
bility, procure sleep, and promote a determination to the skin. In painful dysmen-
orrhea, amenorrhea from recent exposure to cold, after-pains, etc., it will be found
exceedingly beneficial. tThe dose is from ten to sixty drops every hour or two, in
some warm infusion of Catnip, Sage, or Balm, etc.

ARNICA MONTANA.

LEOPARDSBANE.

A plant common to the mountainous districts of Europe and Siberia. I have recently
iployed the flowers of this plant in congestion of the cervix, and ecchymosis of the

690

AMERICAN ECLECTIC OBSTETRICS.

cervix, or that condition which when viewed through the speculum, appears of a dark-
reddish color, leading the practitioner to suspect erosion or ulceration, either of which,
however, will be found absent on a careful examination. The flowers, after having
been steeped in hot water, are to be applied directly to the cervix. This I most
usually accomplish by rolling up a piece of muslin or linen five or six inches in
width, until it forms a roll about an inch and a half in diameter; one end of this is
pressed downward, so as so form a cup-like concavity, in which the Arnica poultice is
placed, and then introduced within the vagina to the cervix, the female standing
during its introduction. The roll is kept in its place by means of a bandage. While
wearing this, the patient must exercise as little as possible. A soft extract may, for
the same purpose, be applied to the cervix through the speculum, and then covered
with lint. These applications will not be required oftener than twice in the course of
twenty-four hours. Muriate of Ammonia should be given internally with such other
agents as may be suited to the peculiarity of each individual case.

ASCLEPIAS TUBEROSA.

PLEURISY ROOT.

A well-known plant common to this country, the root of which possesses diaphoretic
and expectorant properties. It likewise exerts an influence upon the uterus and its
ligaments. It may be used in leucorrhea and prolapsus uteri, alone, or combined with
Unicorn-root, Black Cohosh, Blue Cohosh, Life-root, or Red-root. My usual mode of
exhibiting it is already explained under the head of Aletris Farinosa, which see.
Asclepidin, its concentrated preparation, may be administered with Senecin, Caulo-
phyllin, Cimicifugin, etc., in many uterine maladies with beneficial results. A very
good pill for prolapsus uteri, and indeed for several derangements of the uterine func-
tions, is made as follows :

Jfc. Asclepidin,
Aletridin,

Hydro-alcoholic extract of black Cohosh,
of each, ten grains. Mix.

Divide into ten pills, of which three or four may be taken daily. The hydro-alco-
holic extract of Pleurisy-root will also be found an elegant preparation in uterine
displacements : its dose is from three to ten grains three times a day. The dose of
Pleurisy-root, in powder, is from twenty to sixty grains ; of the infusion, from two to
four fluidounces, every two or three hours ; of the Asclepidin, from one to five grains.

ASSAFCETIDA.

ASSAFCETIDA.

This is the gum-resin or concrete juice of the Ferula Assafcetida, a plant indigenous
jO Persia. It is considered stimulant, antispasmodic, and emmenagogue, and is used
in hysteria, spasmodic nervous diseases of females, and occasionally in amenorrhea
and dysmenorrhea. It should not be used in inflammatory conditions of the system.

MATERIA MEDICA.

691

A very excellent preparation for the sick and nervous headache, to -which many females
are subject, is composed as follows :

Jjfc. Powdered Assafcetida, thirty-two grains,"]
Sulphate of Quinia, eight grains,
Sulphate of Morphia, one grain,
Piperine, sixteen grains. Mix.

Divide into eight powders, of which three may be taken daily. I do not know the
benefit to be obtained from the Piperine, and think it might advantageously be
omitted.

Assafcetida may be combined with Caulophyllin and Cimicifugin, for nervous
derangements depending upon uterine difficulties. The dose of the gum-resin is from
five to ten grains; of the tincture, from half a fluidrachm to two fluidrachms. The
tincture, diluted with some bitter decoction and injected into the rectum, will remove
the thread-worm, ascarides, to which children are liable.

ATROPA BELLADONNA.

BELLADONNA.

A European plant, and an energetic narcotic poison. It is principally employed in
the form of tincture, or alcoholic extract. Belladonna is anodyne, antispasmodic, and
calmative, and is much used in uterine difficulties, especially in dysmenorrhea. The
following pill has proved very efficacious in the treatment of dysmenorrhea :

]£. Camphor, two and a half drachms,
Sulphate of Quinia,
Extract of Belladonna,
Wheat Flour, of each, one scruple,

Water, a sufficient quantity to form a pill-mass. Mix.

Divide the mass into eighty pills. The dose is two pills every hour, at the menstrual
period, until the pain ceases, and one pill every three or four hours during the interval.
The flour is merely added for the purpose of aiding in making a pill-mass. The same
pills will be found useful in neuralgia and rheumatism of the uterus, and to restop*
the nervous system to its normal activity, after a recovery from puerperal convulsions.

In rigidity of the os uteri during labor, it has been recommended to overcome this
condition by anointing the cervix with the extract of Belladonna. '

In neuralgia of the uterus, it has been advised to mix together one grain and a half
of extract of Belladonna, and three-fourths of a grain of Opium. Place the mixture
in the center of a small pledget of carded cotton, fold it up, and tie it with a strong
thread, leaving long ends to the thread so that the whole can be easily removed. This
pledget is to be introduced into the vagina and placed upon the cervix, where it may
remain for twelve or twenty-four hours.

Dysmenorrhea, Leucorrhea, and Chorea, may be frequently cured by the follow-
ing pill:

Extract of Belladonna, three grains,
Strychnia, one grain,

Alcoholic extract of Cimicifuga, two scruples. Mix.

\

692

AMERICAN ECLECTIC OBSTETRICS.

Divide into forty pills, of which one is a dose, to be repeated three or four times daily.

The dose of the tincture of Belladonna is from five to thirty drops : of the extract)
from one-sixteenth of a grain to half a grain.

/

BAPTISIA TINCTORIA.

WILD INDIGO.

This is a small shrub indigenous to various parts of the United States, the root of
which possesses antiseptic properties. Its principal employment in obstetrics is in
irritative fever from putrefactive absorption, where it may be exhibited with much
advantage. I have derived much benefit in such cases from an infusion of two ounces
each of Blue Cohosh root and Unicorn root, and one of Wild Indigo root, in three pints
of water: of this the dose is a tablespoonful every two, three, or four hours, as the
circumstances of the case may demand.

BAPTISIN, the concentrated preparation from the root, in doses of from one-fourth
to half a grain, exerts a marked influence on the glandular and nervous systems, pro-
ducing, if carried too far, a disagreeable sensation with prostration. Yet, in combi-
nation with Leptandrin, Quinia, Podophyllin, Cimicifugin, etc., it will be found valua-
ble in many uterine diseases, in typhoid fever, in the typhoid form of puerperal fever,
and in all diseases of a typhoid character. It also forms an excellent local application
to malignant and fetid ulcerations of the cervix uteri, for which purpose it may be
used alone, or combined with Sanguinaria, vegetable Caustic, Nitrate of Silver, etc.
This plant does not receive that attention from the profession which its virtues entitle
it to.

BIDENS BIPINNATA.

SPANISH NEEDLES.

This plant is common to this country ; the seeds are emmenagogue, and have been
beneficially used in infusion and in tincture in amenorrhea, dysmenorrhea, and other
uterine derangements. The dose of the infusion is from two to four fluidounces three
or four times a day ; of the tincture, one or two fluidrachms.

CALX.

LIME.

This article is introduced here for the purpose of giving the formula for Potassa cum
Calce, also known as Vienna powder, or paste, a powerful caustic, used for cauterizing
the neck of the uterus or other parts. It is prepared by reducing caustic Potassa one
ounce and a half, and Quicklime two ounces, each separately, to powder in a heated
mortar; they are then to be carefully and rapidly mixed, and the mixture kept in a
wide-mouthed bottle with a ground stopper. In using this caustic, moisten the powder
with a little alcohol, so as to reduce it to a soft paste, and apply it only over the part
to be cauterized. The Caustic of Filhoa is more easy to use, and is made by fusing

MATERIA MEDICA.

698

together six ounces of caustic Potassa and three ounces of Quicklime, pouring the
mixture into leaden cylinders inclosed in glass tubes, and which are to be sealed subse-
quently at each end.

J \

CAMPHORA.

CAMPHOR.

A concrete substance derived from Laurus Camphora, a tree indigenous to Asia. It
possesses sedative, anodyne and antispasmodic properties, and is administered to sub-
due pain, allay nervous excitement, arrest spasm, and, in combination with Opium,
Lupulin, or Hyoscyamus, etc., to cause sleep. It has been found highly beneficial in
all irritations of the generative organs, and has been exhibited in neuralgia of the
uterus, dysmenorrhea, after pains, nymphomania, puerperal fever, etc. It enters into
the officinal compound powder of Ipecacuanha and Opium, and the compound tincture
of Virgina Snakeroot. The following pill forms an excellent remedy for those females
who are subject to excessive nervous irritability:

1jc. Powdered Camphor, four scruples,
Powdered Opium, two drachms,
Valerianate of Quinia, half a drachm,
Extract of Stramonium, a sufficient
quantity to form a pill-mass. Mix.

Divide the mass into ninety-six pills, of which one is to be given every night and
morning, gradually increasing the dose.

The dose of Camphor in Powder is from one to five grains ; of the tincture, from five
to sixty drops, in mucilage or syrup.

CAPSICUM ANNUUM.

CAYENNE PEPER.

Cayenne Pepper is a pure stimulant, of much service in dyspepsia, torpor of the
gastric functions, colds, catarrh, hoarseness, and in all cases of diminished vital
action wherever a pure stimulant is indicated. It is also found to be of benefit in
passive hemorrhages, and especially uterine hemorrhage occurring at the period of
parturition. The following preparations have been successfully used in menorrhagia
and uterine hemorrhage:

1. Cayenne Pepper, two scruples,
Opium, four grains,
Ipecacuanha, eight grains. Mix.

Divide into eight powders: the dose is one powder every fifteen, twenty, or thirty min-
utes, as the urgency of the case may require.

2. Calcined Deer's Horn.

Comp. powd. of Ipecacuanha and Opium,
Cayenne Pepper, of each, one drachm. Mix.

694

AMERICAN ECLECTIC OBSTETRICS.

The dose of this is from one to four or six grains, every twenty, thirty, or sixty
minutes.

3. Jt. Powdered sulphate of Iron, two drachms,
Powdered Alum, one drachm. Mix.

Calcine by a red heat, and, when cold, pulverize, and add to every drachm of the
mixture, one scruple of Cayenne Pepper. Keep the mixture in well-stopped bottles.
The dose is from four to six grains, as with the preceding powders.

Capsicum is a prominent ingredient in the compound tincture of Lobelia and Capsi-
cum— a most useful preparation to relax muscular rigidity, and overcome spasmodic
action. The dose of capsicum, in powder, is from one to six grains; of the tincture,
from half a fluidrachm to a fluidrachm.

CAULOPHYLLUM THALICTROIDES.

BLUE COHOSH.

This is a perennial plant, found in nearly all parts of the United States, the root of
which possesses emmenagogue, parturient, and antispasmodic properties. It has been
found efficacious as an internal remedy in leucorrhea, amenorrhea, dysmenorrhea, and
other chronic affections of the uterus. In neuralgia and rheumatism of the uterus it
has frequently been administered with benefit. The decoction used for several weeks
previous to parturition, is said to impart an energy to the uterus, which facilitates
delivery; in which respect it acts as a preparatory parturient; for this purpose it is
sometimes combined with the Mitchella repens, and Eupatoria aromatica. A preparation,
called the Parturient Balsam, is quite a favorite agent with many practitioners for this
purpose, as well as for giving tone and activity to the uterus when its functions are
torpid or impaired, as in amenorrhea, dysmenorrhea, leucorrhea, etc.; it is prepared
as follows:

Blue Cohosh root,

Spikenard root, of each, four ounces,
Black Cohosh root,
Partridgeberry herb,

Queen-of-the-Meadow root, of each, two ounces,
Ladies-slipper root,

Comfrey root, of each, one ounce. Mix.

Grind and mix the articles together, place them in a convenient vessel, cover them
with Alcohol of 76 per cent., and macerate for two days. Then transfer the whole to
» displacement apparatus, and gradually add hot Water, until half a pint of the tinc-
ture has been obtained, which retain and set aside. Continue the percolation until the
solution obtained is almost tasteless, preserving that which contains a sensible amoun-t
of Spirit, from the subsequent solution. Boil down this weaker infusion until, when
added to the second portion obtained, it will make three pints. To these two solutions
combined, add of refined Sugar four pounds, and dissolve it by heat, carefully remov-
ing the scum which arises as it comes to the point of boiling, and evaporating, if
necessary, so that there will be half a gallon of syrup, when the half pint of tincture,
first obtained, is added — which is to be done after the syrup has been removed from
the fire, and is nearly cold. The preparation may be flavored with any pleasant aro-
matic, as essence of Wintergreen, Sassafras, etc.

MATERIA MEDICA.

695

The dose of this compound is from a teaspoonful to a tablespoonful, three or four
times a day.

Given in powder or decoction, Blue Cohosh will frequently be found more desirable
than Ergot, for expediting delivery, in all those cases where the delay is owing to
fatigue, debility, or want of uterine energy; the contractions it occasions, more nearly
resemble the natural ones, instead of the continuous, spasmodic contractions effected
by Ergot. It is sometimes combined with Black Cohosh for this purpose, and some
accoucheurs prefer a combination of equal parts of Blue Cohosh, Black Cohosh, and
Ergot. The compound tincture of Blue Cohosh is frequently employed in amenor-
rhea, dysmenorrhea, and other uterine affections, with much benefit ; it is prepared as
follows :

Powdered Blue Cohosh root, two ounces,
Ergot,

Water Pepper, of each, bruised, one ounce,
Oil of Savin, half a fluidounce,
Alcohol, one pint and a half. Mix.

Macerate for fourteen days, express, and filter; or, it may be made by displacement
The dose is a fluidrachm, two or three times a day.

As a local application, and also administered internally, the infusion of Blue Cohosh
stands unrivaled in aphthous ulcerations of the mouth common to children; it is usu-
ally mixed with an equal quantity of Golden Seal, made into an infusion, and sweeetened
with Honey.

The infusion is made by adding an ounce of the powdered root to a pint of boiling
water, and allowing it to macerate for fifteen or twenty minutes ; the dose is from two
to four fluidounces three or four times a day ; or, to promote uterine contractions,
every fifteen or twenty minutes. The dose of the saturated tincture is from half a
fluidrachm to two fluidrachms. The alcoholic extract of Blue Cohosh, forms an elegant
preparation for amenorrhea, dysmenorrhea, and other uterine diseases; it may be used
alone, or in combination with Senecin, Aletridin, Cimicifugin, or extract of High-Cran-
berry bark. It will likewise be found serviceable in after-pains. An excellent pill for
painful affections of the uterus, is made as follows :

Alcoholic extract of Blue Cohosh,

Alcoholic extract of (High-Cranberry bark, of each, one dram,
Scutellarin, two drahcms. Mix.

Divide into sixty pills, of which one pill may be given every two, three or four hours.
This pill will also be found advantageous, both during pregnancy, and labor, in cases
where there is excessive nervous irritability, restlessness, wakefulness, cramps of
the stomach, or other spasmodic attacks.

The dose of the Alcoholic extract of Blue Cohosh is, from one to five grains, three
times a day.

CAULOPHYLLIN, is the name given to the concentrated preparation obtained from
the root of Blue Cohosh ; it possesses the properties of the root in an augmented degree,
and is at present more generally used. In amenorrhea, dysmenorrhea, leucorrhea,
passive monorrhagia, congestion of the cervix, etc., it has proved very efficacious, and,
in which it may be used alone, or combined with other agents known to exert an influ-
ence on the uterus, and which have been referred to above. It exerts a very decidedly
beneficial influence in severe after-pains, and will be found of much value, after deliv-

696

AMERICAN ECLECTIC OBSTETRICS.

ery, in cases where the uterus is not disposed to contract firmly. Where there has
been a tendency to hemorrha|jp from relaxation of the muscular fibers of the uterus, after
delivery, I have caused firm contractions by the exhibition of a powder composed of
two grains of Caulophyllin, and one of Capsicum, repeating the dose every fifteen or
twenty minutes, or, every hour.

In lingering labor occasioned by inefficient contractions of the womb, Caulophyllin
may be given in doses of from two to four grains, repeated at intervals of fifteen,
thirty, or sixty minutes ; in the course of an hour or an hour and a half, it will most
usually arouse the organ to energetic action. The following pill will be found very
efficacious in all uterine difficulties depending upon a torpid condition of the organ, as
in amenorrhea, dysmenorrhea, etc.:

Iji. Caulophyllin, one scruple,

Podophyllin, one grain and a half,
Alcoholic Extract of Nux Vomica, one grain,

Extract of Water Pepper, a sufficient quantity to form a pill-mass. Mix.

Divide into ten pills, of which one may be given for a dose, and repeated three times
a day.

In one case of inefficient contractions of the uterus, I administered two grains of
Caulophyllin made into a pill with an equal quantity of the extract of the recent inner
bark of the Cotton root ; the second dose was repeated after an interval of half an hour,
and was promptly followed by powerful action of the organ, speedily terminating
the labor, and without any unpleasant results.

The usual dose of Caulophyllin is from one-fourth of a grain to a grain, repeated
two, three, or four times a day.

CEANOTHUS AMERICANUS.

RED ROOT.

An indigenous plant, possessing astringent properties. A strong decoction of the
root has been employed with success in passive menorrhagia, in diarrhea of puerperal
women, and as a local application to aphthous ulcerations of the mouth and throat of
children, as well as in ulceration of the fauces attendant on scarlatina. It has also
been usefully employed as an injection in vaginal leucorrhea. The dose of the decoc-
tion is from half a fluidounce to a fluidounce three or four times a day. It is a valua.
ble agent, not properly appreciated by the profession.

CEPHAELIS IPECACUANHA.

IPECACUANHA.

A South American plant, the root of which possesses nauseant, emetic, tonic, stimu-
lant, and diaphoretic properties. It is much employed in febrile, inflammatory,
painful, and irritable forms of disease, and, usually, combined with Opium and Cam-
phor, as in the compound powder of Ipecacuanha and Opium.

In diarrhea and dysentery, Ipecacuanha, administered in small doses, has been
regarded as a valuable remedy; when much pain is present, sulphate of Morphia may

MATERIA AIEDICA.

697

be added to each dose; say one-eighth of a grain of Morphia, to two or three grains of
Ipecacuanha. If the dysentery is epidemic, the addition of sulphate of Quinia to each
dose, say from half a grain to a grain, will improve the action of the remedy. A
combination of Leptandrin, one grain, Podophyllin, one-fourth of a grain, Ipecacuanha,
one grain, sulphate of Quinia, half a grain, has been successfully administered in
epidemic dysentery ; the above dose to be repeated every three or four hours.

Ipecacuanha, in doses of five or ten grains, has been found very useful in monor-
rhagia ; and combined with Opium and Capsicum, it promptly checks uterine hemor-
rhage. It entei-s into the compound tincture of Virginia Snakeroot, a preparation
which frequently proves beneficial in puerperal peritonitis. See page G89. The dose
of Ipecacuanha as an emetic, is from twenty to thirty grains ; as a nauseant, from five
to ten grains ; as a tonic, from one-fourth to one-half of a grain ; as a stimulant and
diaphoretic, from half a grain to two grains, every three or four hours.

CHLOROFORMUM.

CHLOROFORM.

This article is a sedative-narcotic, and has been employed internally in various forms
of disease, for the relief of pain and nervous irritability. The following preparation
has been recommended in cases of excessive nervousness, and where spasmodic action
exists :

Jje. Camphor Water,

Tincture of Valerian, of each, two fluidounces,
Chloroform, one fluidounce. Mix.

The dose is half a fluidounce every hour or two, or as often as the urgency of the
symptoms require.

Applied to the os uteri, by means of a sponge, Chloroform has proved successful in
dysmenorrhea.

But it is principally on account of its anaesthetic influence that this article is
employed in surgery, and also in midwifery, for the purpose of relieving pain, and
facilitating labor. With regard to its employment during parturition, there is some
discordance of views among the members of the profession, the major part, of whom, I
believe, are rather favorable to its use. That it may be of service in puerperal convul-
sions, or when turning has to b^ employed, or in severe and difficult operations, can not
be denied; but there is considerable danger from its use, even in these cases. For
instance, when the female lies in a state of anaesthetic unconsciousness, unable to
give vent to her expressions, or to warn the operator that he may be doing some mis-
chief, how is he positively to determine that he is not lacerating the vagina, or cervix,
or that a rupture of the uterus has taken place? If the operator is not experienced in
using the forceps, he may include the cervix in its grasp, and not be aware of the
mistake until.it is too late to be remedied. True, these accidents have seldom occurred
when Chloroform has been used, but there is a liability to their occurrence, and one
death resulting from this cause, which would not, probably, have happened, without
the use of Chloroform, should be sufficient to render the practitioner very cautious in
its administration, and also in his mode of operation. Undoubtedly, every accoucheur
should be prepared to operate safely under all circumstances, but when even the most
experienced and skillful fail occasionally, how much greater must be the risk wben the
operator is careless, inattentive, or ignorant, to one of which imputations, too many,
alas, of our practitioners are justly obnoxious.

45

698

AMERICAN ECLECTIC OBSTETRICS.

But, Chloroform is also recommended in ordinary labors, for the purpose of allevi-
ating the sufferings of the female, and when thus used, its full anaesthetic influence is
not usually produced. The motive is, undoubtedly, humane, but the propriety of thus
employing it has been doubted, because, even when under its moderate influence, hem-
orrhage, or some other difficulty, may occur, which, by not being timely observed, may
prove troublesome or serious; and I have witnessed cases in which I have every reason
to believe, that the labors were rendered tedious by the use of the Chloroform.

These may be said to be the principal objections against the use of Chloroform in
midwifery, and should be duly considered by every medical man, without partiality
or prejudice. That the agent may be, and has been employed with immense benefit,
there is not the least doubt, and, notwithstanding the above objections, the weight of
testimony is in its favor. The only questions to determine are, under what circum-
stances to exhibit it, at what period, and to how great an extent. <

As to the circumstances under which it may be used, general rules are all that can
be given. It is well known that there is a great difference among females as to the
amount and intensity of suffering experienced during parturition; some passing
through this period rapidly, and with, comparatively, little pain, while with others the
suffering is intense, whatever may be the duration of the labor. The former do not
require Chloroform, nor any other anaesthetic, but, when the latter are brought par-
tially under its influence, much agony may be prevented, and the system preserved
from the influence of a too powerful nervous shock. Chloroform may also be used in
cases of turning, more especially when the uterus is very irritable, contracting ener-
getically upon the slightest attempt to introduce the hand within its cavity: likewise
in forceps cases, convulsions, and in craniotomy; and the operator should keep con-
stantly before him the possibility of some accident occurring, similar to those which
have been presented as objections to its employment. In operations, and especially
those which are long and painful, the efforts of the operator are frequently embar-
rassed by the resistance of the female, and there will be as much danger of injury to
the soft parts, if not more, than when she lies in a state of anaesthetic passiveness.
Chloroform should be used with a degree of hesitation and extreme caution in crani-
otomj', where sharp instruments are introduced within the female organs, because a
careless thrust, an error of motion, or a slipping of the crotchet, may produce irrepar-
able mischief. There is greater hazard to the female in this operation, than when the
agent is used in turning, or during a forceps operation. Still, in careful and prudent
hands, anaesthesia may be produced in craniotomy, without any of the above-named
evil results being effected.

As to the period for its exhibition and the extent to which anaesthesia should be car-
ried, much must be left to the judgment of the well informed and prudent accoucheur.
I think it v/ere better not to allow too great a degree of prostration to ensue previous
to its inhalation; and, that there is no necessity for the production of complete uncon-
sciousness, except in convulsions, and the more severe operations.

Perhaps the more pertinent question with regard to this agent in midwifery would
be, not to determine when it should be used, but, when shall its exhibition be omitted?
This question is not yet positively settled, but enough has been gleaned to lead us to
be cautious in exhibiting it to females laboring under diseases of the lungs or heart,
those of a plethoric habit, or disposed to congestion of some of the more important
organs, as well as to those who are in a state of great exhaustion.

Anaesthesia may frequently be produced with advantage in cases where it is desired
to reduce a displaced uterus, where the cervix is to be cauterized, where dysmenorrhea
is treated by mechanical means, as well as in other operations upon the cervix, or
vagina.

MATERIA MEDICA.

699

Dr. S. L. Hardy, has successfully employed Chloroform, in vapor, as a local applica-
tion, in all painful uterine diseases. "The application- for applying it consists of a
small metallic chamber; to one end of this a gum-elastic bottle is attached, to the other
a pipe furnished with a valve. On the end of the chamber there is also a second valve,
to admit atmospheric air for the working of the instrument. In order to charge it with
Chloroform it is necessary to unscrew the stopper in the side of the chamber, within
which a piece of sponge is placed for holding the fluid. The quantity poured in should
not be more than the sponge will absorb, otherwise, instead of vapor, fluid Chloroform
will be thrown against the affected part. When charged the vapor may be conveyed
to any part requiring its application by any convenient pipe if closely fitted to the one
on the instrument, pressure being made on the elastic bag to produce expulsion of the
vapor.

"The first effect produced by its application is a sensation of heat, which some com-
plain of more than others, but which in a very few minutes is not referred to, as it is
either more easily borne or soon subsides. If much uneasiness is expressed on account
of it, the action of the instrument may be suspended for a little, or its effect dimin-
ished, which is all that is necessary. When applied per vaginam, on account of pain
in the loins, and sometimes over the pubes, arising from uterine irritation, ' immedi-
ately after the sensation of heat is felt from the presence of the vapor, the pain sub-
aides, first in the back, then in the pubic region.

"I have met with but one case in which chloroform, applied in this manner, did not
remove pain; but in this instance the uneasy sensations were confined to the uterus,
or felt per vaginam, and at the same time the os uteri was very irritable on account of
excoriation, which might account for a greater degree of heat than usual being
experienced.

"The relief afforded by the local application of the vapor of chloroform is not of a
very transient nature. In every instance in which pain was removed by it there was
no return for several hours, and then in a very mitigated degree. In the intervals
great comfort was usually felt. Patients who had previously taken opium, preferred
chloroform, as it caused no unpleasant sensations in the "head next day."

This gentleman occasionally applies an ointment, rubbing it over the loins, or other
painful part, in conjunction; it is made by mixing a fluidrachm of Chloroform, and a
scruple of Camphor, with an ounce of White Wax ointment, to which, occasionally, a
drachm of the extract of Belladonna may be added.

He has successfully employed the vapor douche of Chloroform in dysmenorrhea, car-
cinoma of the uterus, irritable nipples, pruritus pudendi, etc.

The usual mode of exhibiting Chloroform, by inhalation, is, to closely roll a handker-
chief in the hand, making a concavity in it, in which about a fluidrachm of the article
is to be poured ; this is.to be held to the nose and mouth, but not so closely as to pre-
vent the inhalation of atmospheric air with it. Every four or five minutes a fresh
supply of Chloroform, but in smaller quantity, may be added, and inhaled until the
desired influence is effected, which usually takes place in from two to five minutes. As
the anesthetic influence passes off in eight or ten minutes, it will be required to
renew the inhalation from time to time, so as to keep up the incomplete or complete
insensibility for any desired length of time.

The Chloroform used must be pure, or it will produce disagreeable, and perhaps
serious results ; and whenever any unfavorable symptoms arise from its inhalation,
Aqua Ammonia, which should always be held in readiness, must be poured upon
another handkerchief, and the patient made to inhale it instead of the Chloroform.
This will usually restore sensibility, but should it fail, cold water must be applied to
the head and face, which parts should be constantly fanned ; the body and extremities

700

AMERICAN ECLECTIC OBSTETRICS.

should be warmed and rubbed; Galvanism may be applied, and if necessary, artificial
respiration.

"Mr. R. E. Bickersteth, of Liverpool, after much careful investigation, comes to the
following important conclusions on the mode of death from Chloroform :

" 1st. That in death from the inhalation of chloroform, the respiratory movements
cease before the cardiac.

"2d. That the heart continues its action, uninfluenced by the chloroform, for a
period longer or shorter after the cessation of respiration, and that its then failing
may be considered as a natural consequence of the respiration having ceased, and as
independent of the influence of chloroform.

"3d. That if after the respiration has ceased, and while the heart is still in action,
chloroform continues to be absorbed into the system, its movements may become
impaired or cease — the chloroform in such case acting directly upon the heart.

" 4th. That if artificial respiration be resorted to before the cardiac contractions are
seriously affected, and be properly maintained for a sufficient period, the respiratory
functions may be re-established." s

He adds the following highly practical observations:

"I would here direct attention to the expediency of drawing forward the tongue, in
all cases where it is found necessary to resort to artificial respiration. When the
patient is lying on the back, so soon as the breathing ceases and the jaw drops, the
tongue is particularly liable to fall backward and close the orifice of the glottis. Arti-
ficial respiration, under such circumstances, is worse than useless. It is better at
once to pull the tongue well out of the mouth, and passing a hook though the tip, con-
fide it to the care of an assistant. I am convinced that in some cases in which artifi-
cial respiration has failed, it has been from the neglect or too tardy adoption of this
very simple means. Time of the utmost value has been lost in the absurd attempt to
restore animation, by applying stimulants to the nostrils, or pouring cordials into the
mouth, without even a thought that the first can have little or no effect after the respi-
ration has ceased, or that the second would as likely pass into the trachea and bronchi
as into the stomach." — Edinburgh, Monthly Journal.

The following communication is from a practitioner :

" When chloroform was first introduced into use in America, I was called to attend a
woman with typhoid fever, who had been pregnant some six months. After a sickness of
two weeks, her child died, and decomposition commenced without any expulsive effort, or
expulsive power on the part of the mother. I placed her under the influence of chloro-
form, and in four hours succeeded in removing the child.

"During all this time she was sufficiently under the anaesthetic influence of the agent,
as to be free from suffering, and with no unfavorable symptoms; she recovered rapidly

" Shortly after, I attended a patient whose child was born, previous to my arrival, in
the hands of a midwife, and I found her laboring under puerperal convulsions of an
aggravated character. I tried several articles without benefit, until she inhaled chloro-
form, which immediately relieved her, and by frequent repetitions, it entirely removed
them.

"These two cases impressed me so favorably, that since, I have never willingly attended
a case of parturition without having chloroform at my command, and I have very often
administered it, when my object was simply to relieve the patient of pain. I have also
used it preparatory to turning, the application of the forceps, the removal of the placenta,
and the introduction of the hand into the uterus to induce that organ to contract, and
I have never yet had cause to regret its use in any case. I have, however, regretted
that the prejudices of my patients have sometimes precluded its use, as I think, greatly
to the increase of their sufferings, and the loss of my patience and my time.

MATERIA MEDICA.

701

" In short, I have come to consider chloroform as great a boon in the practico of
Obstetrics as in the practice of an}' other department of surgery."

Those who desire more minute information relative to this agent, are referred to the
excellent papers, by Channing, Simpson, Burwell, Parrish, Clark, etc., as well as to the
Report of the Committee on Obstetrics to the American Medical Association of 1849.

CIMICIFUGA RACEMOSA.

BLACK COHOSH.

This perennial plant, also known as MacroUjs Racemosa, is indigenous to the United
States, and is a very active and useful remedy. The root is the officinal part. It pos-
sesses a peculiar influence upon the uterine system, as well as upon the nervous system
generally. Administered internally it is very efficacious in amenorrhea, dysmenor-
rhea, leucorrhea, and other uterine affections, in which it may be used alone, or in com-
bination with other agents, as Asclepias, Aletris, Caulophyllum, Senecio, etc. The
saturated tincture, in combination with the saturated tincture of Aconite, or the tinc-
ture of Gelseminum, forms a highly valuable preparation for rheumatism of the uterus,
neuralgia of the uterus, and the febrile or inflammatory affections which occur at the
parturient period. Combined with the tincture of Colchicum seed, it is beneficial in
acute rheumatism, and in phlegmasia dolens ; for these purposes it has been used in
the following form :

Saturated tincture of Black Cohosh,
Tincture of Colchicum seed,

Tincture of Iodide of Potassium, of each, one fluidounce. Mix.

The dose is a fluidrachm, every two, three, or four hours, as symptoms may indicate#

It may be used as a partus accelerator, a decoction of the root being exhibited. It
does not produce the powerful and continuous contractions of the uterus which follow
the use of Ergot, and consequently is not so dangerous to .the child, neither does it les-
sen the susceptibility of the organ to subsequent doses as is apt to be the case with
Ergot; it appears to excite the uterus to a normal activity only. As a partus accele-
rator, half a drachm of the powdered root, in some hot water, or, half a fluidrachm of the
saturated tincture, may be given for a dose, and repeated every fifteen or twenty min-
utes until the expulsive action of the uterus is induced. It is sometimes given for this
purpose in combination with Blue Cohosh, etc.

After-pains will be relieved by it, as well as the state of general excitement of the
nervous system following delivery.

I prefer the saturated tincture of the root, or its Alcoholic extract, either of which I
consider superior to the concentrated preparation, Cimicifugin.

In leucorrhea, prolapsus uteri, relaxation of the vaginal walls, and excoriation of the
cervix, the following vaginal injection will prove advantageous:

Powdered Black Cohosh root,

Powdered Cranesbill root, of each, two ounces,

Boiling Water, four pints. Mix.

Cover the articles, digest for an hour or two, and strain. About two fluidounces may be
injected at a time, and which should be repeated three or four times a day.
' The dose of the powdered root, is from a scruple to a drachm, repeated three or four
times daily; of the saturated tincture, from five to sixty drops; of the infusion, from
two to four fluidounces. It will be found to exert a powerful influence on some patients,

702

AMERICAN ECLECTIC OBSTETRICS.

even when given in very small doses, while with others the maximum dose exerts no
appreciable effect. The fluid extract of Black Cohosh, may be used in all cases where
the article is indicated ; its dose is from half a fluidrachm to two fluidrachms. Dose
of Alcoholic extract, from one to five grains.

CIMICIFUGIN (or Macro tin), is the name given to the concentrated preparation
obtained from the root of Black Cohosh; it is much used by practitioners as a substi-
tute for the crude article, but I do not consider it to possess all the medicinal virtues of
the root, though it is undoubtedly a valuable remedy in uterine affections, in which it
may be advantageously combined with Aletridin, Caulophyllin, Asclepidin, Senecim
etc. Leucorrhea, menorrhagia, amenorrhea, dj'smenorrhea, prolapsus uteri etc., have
been decidedly benefited by its administration. As a parturient I deem it inferior to
Caulophyllin. The dose is from half a grain to six grains, three times a day.

Mr. E. Wayne, of Cincinnati, one of our most thorough chemists, has made a pre-
paration from the tincture of the root, which possesses all its medicinal virtues in a
concentrated form. The saturated tincture of the root is allowed to evaporate sponta-
neously, when there is deposited a solid mass ; the remaining fluid is poured from this,
the mass is dissolved in Alcohol, slowly evaporated to the consistence of a fluid extract,
and is then placed in thin layers on glass and allowed to dry. The preparation has
the peculiar smell and taste of the root, and, as far as tried, appears to be superior to
any other preparation of the article. About one ounce is obtained from two pounds of
the root, and which can well be afforded for one dollar and fifty cents. It should not be
washed in water, as this removes some of its medical properties. I have no doubt but
that this preparation will supersede the use of our present Cimicifugin. The little
experience I have had with it, leads me to consider it at least equal, if not superior, to
the Alcoholic extract, or the saturated tincture of the root.

CINNAMOMUM ZEYLANICUM.

CINNAMON.

This tree is a native of Ceylon, Sumatra, Borneo, etc., the bark of which furnishes
the Cinnamon of commerce. Cinnamon exerts an influence upon the uterus, independ-
ent of any astringency, which not only renders it useful in uterine hemorrhage and
menorrhagia, but disposes the pregnant female to a miscarriage. Indeed, Cinnamon and
Borax, mixed together in the proportion of ten grains each, have been administered
with the criminal intention of procuring an abortion. It is, however, only in uterine
hemorrhage in which this agent is advised, and it may be exhibited either in the form of
tincture of the bark, or the essence; or either of these may be combined with other
astringents, as tincture of Rhalany, spirits of Turpentine, tincture of Kino, etc. The
dose of the tincture, or of the essence, is from half a fluidrachm to a fluidrachm, in a
wineglass of sweetened water; to be repeated every ten, fifteen, or thirty minutes,
according to the severity of the flooding. In hemorrhage with much prostration, the
following preparation has been administered with success:

|fc Tincture of Cinnamon,

Tincture of Rhatany,

Tincture of Ergot, of each, one fluidrachm,
Port AVine, three fluidounces. Mix.

The dose is a fluidounce, as often as required.

MATERIA MEDICA.

703

COFFEA ARABICA.

COFFEE.

Green Coffee, powdered, and made into a strong decoction will be found a superior
remedy in amenorrhea, where symptoms of the menstrual struggle are present, as man,
ifested by fullness of the head, and pains of the back and loins. Its use should be pre-
ceded by a mild purgative, and aided by the warm foot-bath ; the dose of the decoction
is a wineglassful every half hour or hour.

CON V ALL ARIA MULTIFLORA.

Solomon's seal.

An indigenous, perennial plant, the root of which has been found of considerable
value in leucorrhea, menorrhagia, and female debility. It is most commonly used in
the form of compound wine of Comfrey, known as the Restorative Wine Bitters, and
which is prepared as follows:

Tfc. Solomon's Seal Root,
Comfrey-root,

Spikenard-root, of each, bruised, one ounce,

Chamomile Flowers,

Columbo-root,

Gentian-root, of each, bruised, half an ounce.

Place the herbs in a vessel, cover with boiling water, and let the compound macerate
for twenty-four hours, keeping it closely covered; then add Sherry Wine four pints,
macerate for fourteen days, express, and filter.

The dose is from a tablespoonful to a wineglassful three or four times a day; and it
forms a most valuable tonic in all diseases peculiar to females.

Solomon's Seal exerts a beneficial influence upon irritable and inflamed mucous sur-
faces, and is hence efficacious in chronic inflammation of the mucous lining membrane
of the intestines, and in piles, diarrhea, and dysentery. The following has afforded
considerable relief to pregnant females suffering with piles, and has effected cures at
other times: Take of Solomon's Seal four ounces, powdered Resin two ounces, boiling
water two pints, . Molasses one pint. Simmer gradually to one pint and a half, and
strain. The dose is a wineglassful three or four times a day.

CORNU CERVINE CALCINATUM.

CALCINED DEER'S HORN.

This is prepared from the horns of the deer, Cervus Virginianus. These are to be
gathered while in velvet, or during the period between August and December, just before
they fall off. Horns which have fallen from the deer will not answer. They are to be
reduced to a coarse powder by means of a rasp, placed in an iron vessel, covered up
tightly, and exposed to a heat of 195 to 200 deg., with constant agitation of the pow-
der, and which should be continued for forty-eight hours, or until the whole becomes

704

AMERICAN ECLECTIC OBSTETRICS.

of a light brown color, like roasted coffee, and is easily pulverizable. Then, when cool,
pulverize it, and keep it in well-stopped bottles.

This powder is a powerful styptic, and is of much efficacy in monorrhagia and uter-
ine hemorrhage. From its promptness in checking hemorrhage after delivery, it may
probably possess some influence upon the contractile power of the muscular fibers of
the uterus, aside from its styptic action. It is given in drachm doses of the powder,
repeated every half hour until the hemorrhage ceases permanently; or, a drachm of
the powder may be added to a gill of hot water, and a tablespoonful of the infusion be
administered every five or ten minutes. It most generally lessens the discharge soon
after the first full dose, seldom requiring more than the third to cause its permanent
cessation. Some practitioners combine it with the compound powder of Ipecacuanha
and Opium, Capsicum and Opium, etc., and, as they suppose, with increased benefit.

CYPRIPEDIUM PUBESCENS.

YELLOW LADIES-SLIPPER.

An indigenous, perennial plant, sometimes called Nerve Root, American Valerian, etc.
There are several varieties of this plant, the roots of which are stated to be tonic,
stimulant, and antispasmodic. It is extensively used in the nervous disorders of
females, both during pregnancy and in its absence. In the following combination, it
forms a valuable remedy for the nervous headache to which many females are subject.

]J. Alcoholic extract of Yellow Ladies-slipper,
Alcoholic extract of Black Cohosh,
Scutellarin, of each, one drachm. Mix.

Divide the mass into sixty pills, of which one may be taken every two, three, or four
hours. This will also be found beneficial in many instances of nervous irritability
accompanying affections of the uterus, as well as in sleeplessness during pregnancy.

The fluid extract is an eligible form, and may be substituted in the above prepara-
tion, being mixed with the fluid extracts of the other articles.

The dose of the powdered root is from ten to sixty grains; of the tincture, from one
to three fluidrachms ; of the alcoholic extract, from one to fifteen or twenty grains ; of
the fluid extract, from half a fluidrachm to a fluidrachm — the dose of either prepara-
tion to be repeated three or four times a day.

CYPRIPEDIN, is the name given to the concentrated preparation obtained from the
root. It possesses all the virtues of the root in an increased degree, and may be
administered in doses from half a grain to three grains, three or four times a day.
Scutellarin, Caulophyllin, Cimicifugin, Valerianate of Quinia, etc., may be advantage-
ously added to it in many instances. It may be prepared as follows: Distill off the
Alcohol from the tincture of the Ladies-slipper root until it is of a syrupy consistence,
and then precipitate the resin with water, and carefully wash away the pectin and
other soluble matter, which will leave a nearly pure, but not chemically pure resin.
This, however, is not the semifluid or oleo-resinous preparation which has been used
for the last three or four years, and which is obtained by a mode of procedure similar
to that for procuring Iridin, Asclepidin, Podophyllin, etc.

MATERIA MEDICA.

705

DATURA STRAMONIUM.

STRAMONIUM.

A bushy, annual plant, growing in various parts of the world, and quite common to
this country. The leaves and seeds are the parts employed, and possess similar proper-
ties. It is a powerfully narcotic poison in large doses, but may be safely and benefi-
cially exhibited in small ones. It has been employed in the form of tincture, and
extract, in uterine difficulties, especially in dysmenorrhea, neuralgia of the uterus,
and in puerperal fever. In peritonitis, gastritis, enteritis, severe pains in the back
and loins, acute phlegmasia dolens, etc., I have found the use of a poultice of the
fresh leaves, bruised, one of the most efficacious local applications I have ever met
with, promptly subduing the inflammation and allaying pain. (See my remarks on
pp. 627 and 641.)

In painful affections of the limbs or joints, the poultice of fresh leaves, or a plaster
of the alcoholic extract, will be found very beneficial, as also to swelled breasts, pain-
ful hemorrhoidal tumors, and neuralgic pains. In the periodical headache common to
some females, the following pill will be found of service :

Extract of Stramonium, from one-fourth of a grain to one half,

Sulphate of Quinia, two grains,

Sulphate of Morphia, one-fourth of a grain,

Mix with simple syrup, for a pill.

One pill to be taken two or three times a clay. In some cases it will be found advisa-
ble to omit the Morphia, and substitute one grain of Capsicum.

The dose of the tincture of the bruised seeds, is from five to forty drops, two or three
times a day, gradually increased, if required, until it affects the system; of the
alcoholic extract, from the one-sixteenth of a grain to a grain, two or three times a day.

DIOSCOREA VILLOSA.

WILD YAM.

A very valuable perennial, indigenous'plant, the root of which is stated to be anti-
spasmodic; but its properties are not thoroughly and satisfactorily ascertained. It is
very valuable in the nausea and vomiting of pregnant women, in spasm or cramp of
the stomach, and other spasmodic affections, and may be used alone, or in combination
with the Cornus Sericea, or the Viburnum Opulus. It is usually given in decoction
of the root, of which from two to four fluidounces may be given for a dose, and
repeated every half hour until relief is obtained. In bilious colic it is superior to any
other article known, giving prompt and permanent relief in the most severe cases: the
above dose may be repeated every fifteen minutes in this affection.

DIOSCOREIN, is the name given to the concentrated preparation obtained from the
root, and which bears the same relation, as a specific, to bilious colic, as Quinia docs to
intermittent fever. It is also useful in flatulence, borborygmi, etc., in which it may be
given alone or in combination with Asclepidin, Ginger, etc. In after-pains, a combi-
nation of Dioscorein, Caulophyllin, and Viburine, equal parts of each, will be found of
value, as well as in cramps of the stomach, and painful spasmodic affections of the
bowels ; and in the nausea and vomiting of pregnant women, it may be efficaciously

706

AMERICAN ECLECTIC OBSTETRICS.

combined with the extract of Cornus Sericea. In many uterine affections, benefit will
be gained by uniting it with Senecin, Aletridin, Cimicifugin, Caulophyllin, etc. The
dose is from one to three or four grains, repeated as often as the urgency of the symp-
toms require. In bilious colic, it is usually exhibited in doses of four grains, rubbed
up with a tablespoonful of brandy, and repeated in about ten or twenty minutes.

ERECHTHITES HIERACIFOLIUS.

FIKEWEED.

An indigenous, annual plant, possessing tonic, alterative, and astringent properties.
A decoction of the plant, or a spirituous extract, has proved useful in profuse men-
struation, and in (he summer complaint of children. The volatile oil, however, is prin-
cipally used in obstetric practice, to check the uterine hemorrhage, which it frequently
does with promptness. It has likewise been found useful in spasms of the stomach
and bowels, hysteria, and the diarrhea of pregnant females. Triturated with extract
of Stramonium, it affords an elegant application for piles. The dose of the oil, is from
five to twenty drops, on sugar, or in emulsion.

ERIGERON CANADENSE.

CANADA FLEABANE.

r An indigenous, annual plant, common to the northern and middle sections of the
United States. The volatile oil is stimulant and carminative, and exerts a powerful
influence in menorrhagia, and uterine hemorrhage. From two to ten drops, on sugar,
or dissolved in alcohol and mixed in a little mucilage or sweetened water, may be
administered in uterine hemorrhage, and repeated every ten or twenty minutes, as
required ; it usually acts promptly. It may p#ssibly have some other influence in
checking uterine hemorrhage, than that of a mere astringent, for, without the muscu-
lar fibers of the uterus are caused to contract, I do not believe the hemorrhage, after
delivery, can be checked. It is sometimes combined with tincture of Ergot, essence of
Cinnamon, tincture of Cinnamon bark, tincture of Rhatany, or Laudanum, with
advantage.

The oil will likewise be found useful in diarrhea, dysentery, and summer complaints
of children; and mixed with five or six parts of Castor Oil, or of Stramonium oint-
ment, it forms a valuable application to piles.

FIRING.

Obtain a thick iron-wire shank, about two inches long, and inserted into a small
wooden handle; on its extremity, which must be slightly curved, have a disk or but-
ton of iron, exactly one-quarter of an inch thick, and half an inch in diameter. The
whole instrument to be only six inches in length. The face of the disk for application
must be flat.

To apply it, light a small spirit lamp, and hold the button over the flame, keeping the
forefinger of the hand holding the instrument at the distance of about half an inch from

MATERIA MEDICA. 707

the button. As soon as the finger feels uncomfortably hot, the instrument is ready for
use, and the time required for heating it to this degree, will be about half a minute. It
is to be applied as quickly as possible to the parts, the skin being tipped successively,
at intervals of half an inch over the affected part, as lightly and as rapidly as possible,
always taking care to bring the flat surface of the disk fairly in contact with the skin.
In this way the process of firing a whole limb, or the loins, making about one hundred
applications, does not occupy much longer than a minute, and the one heating by the
lamp suffices. To ascertain whether the heat be sufficient, look sidewise at the spots as
they are touched, and each spot will be observed to become of a glistening white, much
whiter than the surrounding skin. In from five to thirty minutes the skin becomes
bright red, and a glow of heat is felt over the part. The iron must never be made red-
hot — it is to be very little hotter than boiling water — should never make an eschar, and
rarely raise a blister. On the next day after its application, a number of circular, red
marks will be seen on the skin, the cuticle not even being raised, and the surface ready,
if necessary, for a fresh application. There is no discharge whatever, and in most,
cases the patient is unconscious of what has been done. It is vastly superior to a blis-
ter in many cases ; even the most delicate female will not object to its frequent repeti-
tion when required.

This is a powerful counter-irritant, and has been recommended in paralysis, rheuma-
tism, sciatica, lumbago, etc. I have found it useful in checking abortion, especially in
cases of habitual abortion, to be applied every day or two at the aborting period, in
connection with the other internal treatment ; it must be applied over the sacrum. It
will also be found beneficial in relieving pains in the back and loins from uterine dif-
ficulties.

GALIUM APARINE.

CLEAVERS.

An indigenous, annual plant, possessing refrigerant and diuretic properties, and
which is useful in suppression of urine, heat of urine, inflammation of the kidneys
and bladder, and in all febrile and inflammatory diseases. It is generally given in
infusion, made by macerating an ounce and a half of the herb in a pint of warm
water, for two hours, of which from two to four fluidounces may be given when cold,
and repeated three or four times a day.

The inspissated juice is useful in lichen, cancer, psoriasis, lepra, eczema, and scrof-
ula, and may be given in one or two drachm doses, repeated three times a day. The
infusion made with cold water, is said io be efficacious as a local application for remov-
ing freckles from the face, as well as in several obstinate cutaneous eruptions; the
diseased parts must be washed with it several times a day, and, in case of freckles,
continued for two or three months.

GALVANISM.

Galvanism, or electro-magnetism, has been frequently applied with success in many
uterine diseases, and for several purposes during parturition. It has been employed
in dysmenorrhea, amenorrhea, prolapsus uteri, and in several difficulties connected
with pregnancy and labor. I have never used it in labor, but have found it a valua-
ble agent in many diseases common to females.

708

AMERICAN ECLECTIC OBSTETRICS.

r Dr. Thomas Radford of Manchester, England,* was first led to its use in midwifery,
from observing its value in a case of atony of the bladder. lie has used it
"1st. In cases of tedious labor arising from uterine inertia.

2d. In cases of accidental hemorrhage, either before or after the rupture of the mem-
branes, and especially when exhaustion from loss of blood exists.

*As but little attention has been paid to this subject in our own country, the following quotation is
given entire from Braithwaitc's Retrospect, part 29, pp. 259-2G8, and which, it is to be hoped, will not
only fully repay the reader for his trouble of perusing it, but will induce him to make further investiga-
tions of the powers of an agent possessing such apparently valuable and important uses. The article is
by Dr. Eobert Barnes, Lecturer on Midwifery to the Royal Free Hospital Medical College.

" Defective uterine action does not always indicate a resort to the ordinary means of stimulating the
uterus. There are no occasions in obstetric practice in which nicer discrimination — a more accurate
diagnosis — is required, before deciding upou the means of relief, than in those cases where the contrac-
tile energy is at fault. Our choice must frequently lie between the use of agents calculated to excite
contraction and those which have a directly opposite effect. We are frequently called upon to determine
whether it be better to rouse the energies of the uterus, or to resort to manual or instrumental assist-
ance. Upon our interpretation of the symptoms, and our appreciation of all the circumstances of the
case, our selection of the mode of interference will depend ; and upon this selection may hang the safety
or the destruction of the patient.

If it be difficult to solve the preliminary question, whether we should endeavor to excite the uterus to
action or not, how cautious ought we not to be in our choice of the particular means for inducing con-
traction, when that course is determined upon ?

The action of Ergot of Rye, and the Objections to its use. — There is one agent frequently — much too fre-
quently— resorted to on account of its power of exciting uterine contraction, the Ergot of Rye. A
principal object of this paper will be to exhibit the dangerous properties of this drug ; to show what
little mastery we have over its action when once administered, and the consequently fatal results attend-
ing an error in diagnosis — a mistake in the application of the drug. If I further succeed, as I hope to
do, in proving that we possess another agent at once more effective, more manageable, and more safe,
and capable of useful application in all those cases in which Ergot of Rye is commonly employed, I shall
not have uselessly engaged the time of the reader.

The Ergot of Rye is c pable, under certain circumstances, of producing the most marked and decisive
effect in exciting the ut<r is to contract. An agent possessing such a power, it need not be said, is liable
to abuse. It is notorious that many practitioners carry this drug in their pockets, esteeming it an indis-
pensible adjunct to the practice of michvifery. It is among midwives — necessarily the most ignorant of
obstetric practitioners — that this custom chiefly prevails. That this should be so is most deeply to be
deplored. No agent, no species of interference in natural parturition, supplies more frequent or more
distressing illustrations of that maxim, the most trite, the truest, and the most neglected, 'a meddle-
some midwifery is a bad midwifery,' than does the Ergot of Rye. For one woman who has derived sub"
stantial benefit from its use at the time of labor, it may confidently be assumed that one hundred have
found reason in lo g-enduring subsequent sufferings to rue the hour when they were made to swallow
the nauseous draught under the delusive premise for a speedy release from pangs, hard indeed to bear,
but mostly beneficial in their result.

In discussing the uses of Ergot in obstetric practice, I think it more convenient to postpone the con-
sideration of its use in inducing premature labor, and to refer in the first place to its employment in
labor at the full time. When Ergot is administered before the expulsion of the child, the effects are
usually as follows : In virtue of its peculiar property of exciting contraction of the uterus, in about
fifteen or twenty minutes the uterus is perceived to be under the influence of the drug. A spasmodic
contraction begins in the uterine muscular fibers. Whether this is excited by the direct stimulus of an
ergotic element carried in the blood to the uterus, and thus acting immediately upon the uterine nerves,
or muscular fiber, or whether the ergotic element acts primarily upon the spinal marrow — that is, whether
the first step in ergotic labor is of eccentric or of centric origin, it is not easy to determine. But it is quite
certain that when once the contractile energy of the uterus is roused, that other actions, violent in pro-
portion to the effects on the uterus, arc brought into operation. Secondly, diastaltic or reflex action of
the expiratory muscles is induced with a violence in direct relation to the violence of the primary uterine
contraction. If there be no invincible! obstruction to the expansion of the mouth of the womb and the ex-
pulsion of the child, the child will be driven with precipitate fury through the pelvis and os externum, at
the imminent risk, however, of lacerating the perineum, which has had no opportunity of expanding gradu-
ally and safely, as it does before the normal pressure of a labor completed by the natural powers. It should
be respected as a fundamental axiom in obstetrics, that as child-hearing is a natural function, so is its
safe fulfillment insured by adequate contrivance. Each step in the long process of parturition — from
the first action of the uterine muscular libers which determines the expansion of the os uteri, to the final

MATERIA MEDICA.

709

3d. In casey of ''placenta procvia," in which the practice of detaching the placenta
is adopted, and the vital powers are greatly depressed.
4th. In cases of internal flooding hefore or during lahor.
6th. In cases of post-partum floodings.

contractions which expel the placenta and close the open mouth of the uterine vessels— is only one of a
gradation disposed according to a pre-ordained order, with a view to the final result. To invert or to
disturb this order, as the use of Ergot in natural labor can hardly fail to do, by anticipating the due
period of the expulsive pains, is to disconcert all the arrangements of nature; to throw the whole pro-
cess of parturition into confusion ; to resign to the uncontrollable fury of spasmodic action that process
which depends for its safe completion to mother and child on a regular co-ordination of physiological
actions, in which each stage is essential to the proper progression of the succeeding one.

But if an unforeseen obstruction exist, then more terrible results must be apprehended. When an
obstruction occurs in the course of labor, it frequently happens that nature takes the alarm ; the
uterus, so to express it, seems gifted with a kind of prescience that the obstacle is beyond its power to
overcome. It therefore intermits or ceases those contractile efforts, which, if continued, would
entail either rupture of its own structure or impaction of the child: the contractions become abortive
Now, when Ergot is given, it is presumed that a reason is discovered for its use in the intermission or
cessation of the pains. This intermission or cessation may arise —

1st. From this prescient reluctance of nature to act in the face of a mechanical obstacle.

2d. From exhaustion, in consequence of long-continued unavailing efforts.

3d. Because the proper time for expulsive efforts has not yet come, and the proper physiological stimuli
to diastaltic action have not come into operation.

Now, in every one of these cases the action of the Ergot of Eye is likely to be prejudicial ; first, if in
the case of an obstacle to the progress of the child, Ergot be given, and its peculiar action ensue (which
fortunately is not always), then the uterus contracting, and vainly contracting, upon the opposing force,
is goaded by opposition into more furious efforts. Before its ungovernable struggles something must
give way. Rupture of the womb is one probable termination ; or the child may be jammed in an unfa-
vorable position into the pelvis and there impacted, and convulsions and death may close in the scene,.
All this I have actually witnessed.

When the contraction has ceased from exhaustion, to what purpose will you lash the jaded uterus to
renewed exertions of which it is incapable ? In such a case Ergot can manifestly have none but the most
injurious effect. And yet it is in such cases that it is frequently resorted to.

It may be urged that these are not fit cases for the use of Ergot, and that its injurious action here can
not be advanced as an argument against its employment in proper cases. This may be so. But then
how difficult is the diagnosis — how fatal a mistake ! And if Ergot bo a drug in such common and exten-
sive use as it is known to be, and that among the most ignorant, how can we expect the diagnosis to be
just, or that errors shall not be frequently committed ?

The uncontrollable action of the drug when once administered, added to the difficulty of diagnosis,
constitutes the gravest objections against it. A mistake is irretrievable; once given the case is as it
were out of our hands. We know of no certain means of mitigating or counteracting its effects when
they turn out to be violent or altogether injurious. I propose to pass in rapid review some of the proofs
of the dangers attending the use of Ergot in obstetric practice, dangers too much overlooked, if not
ignored, by many.

I will first consider the dangers to the mother.

Rupture of the uterus. — Dr. Trask, who analyzed the histories of all the cases he found recorded, found
that in a large proportion Ergot has been given. It is quite true that in many of these cases the Ergot
was given in contravention of the rules usually laid down. In some there was obstruction to the labor
from distortion of the pelvis, mal-position or mal-proportion. But this consideration docs not diminish the
value of the general fact, that Ergot has frequently caused rupture of the uterus. If given before the head
has descended into the pelvis, who can determine, even in the case of a well-formed pelvis, that an obstacle
will not arise in the unusual or morbid enlargement of the head ? If given even when the head is pressing on
the perineum, the os perfectly open, and all those conditions apparently present which are held to justify the
resort to Ergot, who can tell whether a second or a third child miiy not be behind ? And who would know-
ingly goad the uterus into spasmodic fury in case of twins ? How great is the probability that the second
child would be driven into the pelvis in a transverse position ? Even up to the moment when the head
is about to emerge from the outlet the use of Ergot then is not safe, and I shall presently show that it is
not necessary.

The next accident is rupture of the perineum. The danger of this accident is so obvious that I need not
do more than record it.

Lacerations of the os uteri, subsequent inflammation, and hypertrophy of the cervix, are events which 1
have frequently traced back to ergotic labor.

710

AMERICAN ECLECTIC OBSTETRICS.

■ 6th. In cases of hour-glass or irregular contraction of the uterus.

7th. To originate, de novo, uterine action, or in cases in which it is desired to induce
premature labor.

Prolapsus and procidentia of the uterus and bladder. — These distressing affections are not unfrequently the
secondary result of inflammation and hypertrophy of the cervix uteri ; but even when not thus tho indi-
rect consequence of ergotic labor, they may result directly from violent dislocation occasioned by Ergot
contractions. I have known a striking case of this kind.

CaseX. — A woman had Ergot given to her in a perfectly natural labor, to expedite delivery. It brought
on one continued pain of a character and intensity such as she had never experienced before, and during
which, to use her own expression, she felt as if "the whole of her body was coming from her." The child
was violently extruded, and the uterus and bladder were driven down by the secondary excited action of
the expiratory muscles into the pelvis, the bladder remaining outside the labia pudendi. It was not
Until some time had elapsed, and careful general and local treatment, that these organs were restorod to
their normal position.

Ergot may induce certain injurious effects upon the mother's system. Dr. Hardy relates, that In
"several cases where the circulation of the patient had undergone depression from 1he action of Ergot,
the effect continued for several days, notwithstanding in some instances the inflammation of the uterus
followed delivery, and the uterine tumor not unfrequently remained much larger than natural, oven
when there was no inflammation." Dr. Hardy also quotes the eminent authority of Dr. Johnson to the
fact that " the volume of the uterus is often found much greater than after ordinary labors, imparting to
the hand almost the feel of a uterus before the expulsion of the placenta."

Drs. Hardy and M'Clintock have observed a marked diminution in the frequency of the mother's pulse
In from fifteen to twenty minutes after the administration of Ergot. And all concur in noticing the
dangerous depression following the use of Ergot when given in cases where the powers of the system
have been reduced by hemorrhage. In one such case Ergot was almost immediately followed by most alarm-
ing symptoms, and depression requiring the most powerful stimulants. In several cases the depressed state
of the circulation continued several days.

Dr. Inglcby relates the following case : " A highly-esteemed friend once found it necessary to pass his
hand into the uterus to remove an adherent placenta, the Ergot of Rye having been previously adminis-
tered. The introduction was carefully performed. The straining and opposition to his efforts on the
part of the woman were exceedingly great, and at the moment when the operator's hand had reached
the organ, my own hand making counter-pressure on the abdomen, the patient became violently con-
vulsed, and died in less than a minute." The cause of tho convulsion, Dr. Ingleby expressly states, was
not loss of blood.

We will now consider the injurious effects of Ergot upon the child.

Drs. Hardy and M'Clintock observed that the pulsations of the fetal heart underwent a similar dimi-
nution in frequency to that witnessed in the mother, and that this was succeeded by irregularity and
Intermissions, and that it became inaudible. Dr. Hardy, Dr. Beatty, and others, after careful
observation directed to this point, assert that unless the child be born within a limited interval from the
administration of the drug, it will be still-born. The excessive mortality of the children in ergotic labor
is a fact well-established, although disputed by some practitioners enthusiastic in the praises of Ergot.
The Prefect of the Seine had observed an almost regular annual increase in the number of still-born
children, and he was informed that in a large number of these cases Ergot of Rye had been given during
labor. He put the following question to the Academy of Medicine : "What may bo the influence of Ergot
of Rye on the lives of infants, and on the maternal life?" The report made by a commission of tho
Academy, consisting of Orfila, Adclon, Villeneuve, Merat, and Danyau, contained the following conclu-
sion : " Ergot of Rye administered improperly causes death to the fetus, and injury to the mother." The
immediate source of danger to the fetus is either the toxical property imparted to the blood, or the inter-
ruption to the circulation through the uterus and tho placenta, occasioned by the long-continued con-
traction of the uterus. In this latter case the child may perish from asphyxia. These are the usual
sources of danger ; but there is a third. The long-continued and violent pressure to which the child is
subjected during ergotic labor may compress the brain beyond tho limit of endurance, or it may impede
the circulation through the umbilical cord. The toxical agency of the Ergot upon the fetal heart is
exemplified in the observation already referred to of Dr. Hardy. The influeice of contraction of the
womb in arresting the circulation through the placenta, and consequently the fetal circulation, has been
demonstrated to me by actual observation. The case is so interesling, and the opportunity of making a
similar physiological experiment must be so rare, that I will cite it in detail.

Case 2. — A woman, with an extremely contracted pelvis, and who ten years before had been delivered
by craniotomy by Dr. Walter, consulted me about her condition. She was again pregnant. I became
satisfied of the propriety of inducing premature labor ; and tho agent I determined upon employing was
galvanism. Having waited until it was estimated that seven months of gestation had passed, the opera-
tion was commenced. I shall have to relate presently the course of the labor under the use of galvan-

MATERIA MEDICA.

711

8th. In cases of abortion, when the indications show the necessity, or justify the
expulsion of the ovum.

9th. In cases of asphyxia in infants.

ism, and may therefore pass at onco to the particular point it is my present wish to illustrate. When
labor had set in, and the os uteri was partially expanded, the cord came down into the vagina. The
pains being of a languid, uncertain character, the galvanic stimulus was kept up. The pulsations of the
cord were strong, and 80 in the minute. Galvanism was applied during the pains ; the contractions
were sensibly increased in force, and during the contractions the pulsations in the cord became inter-
mitting, and occasionally stopped. As the pain went off, and as the galvanism was discontinued, the
pulsations resumed their former strength and regularity. I then tried the effect of galvanism in the
absence of a pain. Contractions were induced, and the intermittonco of the pulse followed.

I then observed the effect of a pain uninfluenced by galvanism. The intermittence of the pulse was
the same. I repeated these observations several times, and always with the same result. Toward the
termination of the labor a strong expulsive pain came on, during which, the head, which was very small,
was driven into the vagina, without, however, causing any pressure upon the cord. During the strong
pain the pulsation in the cord stopped entirely, but returned when tho pain went off.

But fetal circulation is arrested during the physiological contractions of the womb for a short time
only, and is completely restored during intervals sufficiently long to insure the safety of the child. In
orgotic contraction the interruption is total, unremitting, and protracted. Shall we wonder if the child
occasionally perishes from asphyxia ?

Dr. Ramsbotham, whose experience in the use of Ergot in inducing premature labor is probably greater
than that of any other practitioner, says: "After a great number of trials, I observed that although the
mothers recovered as well as if through an ordinary labor, their systems not being in any sensible degree
injuriously affected by the drug, yet that the proportion of children still-born was greater than when
the membranes were punctured. This I attributed to the baneful influence of the medicines upon the
fetus." Dr. Ramsbotham modified his practice in consequence. He further says that " Wright's experi-
ments prove decisively that the medicine has a most prejudicial influence upon the young in tttero, even
to their destruction."'
If the child survives the perils of ergotic labor, is it free from subsequent danger ?

Dr. Ramsbotham says : " It has happened to me in four different instances to witness the death of tho
fetus, a few hours after birth, by convulsions, after the induction of premature labor by Ergot."

Those facts, which might be greatly multiplied, prove beyond a doubt that Ergot of Rye is capable of
exerting the most deplorable and even fatal mischief both upon tho mother and the child. It follows
from this circumstance, the uncontrollable nature of its action, and the difficulty that exists in many
instances of forming an accurate diagnosis, that the use of Ergot of Rye in obstetric practice should be
reduced within the narrowest possible limits. I believe that the restrictions to its use must be carried
very much further than is generally prescribed. It is a matter of extreme doubt to me whether it should
ever be administered before the child is born ; and in cases of uterine inertia after delivery, accompanied
with retention of the placenta or hemorrhage, it has been shown to be by no means free from objection.
But the most effectual way of attaining the object I propose, of minimising the use of Ergot in obstetric
practice, is to show that we possess other means at once more safe, more effectual, and capable of suc-
cessful application in all those cases in which Ergot has been recommended. — Lancet, Nov. 5, 1853, p. 433.

[ Dr. Barnes, passing over all these slighter stimulants to uterine action, such as restoring hope and
confidence in the patient, pressure of the hand on the womb, application of cold, etc., proceeds to
consider tho value of galvanism as a substitute for Ergot.]

From time to time many valuable but isolated observations upon the use of galvanism in different
cases of obstetric practice have been published. But no systematic attempt has been made to prove that
in galvanism we possess an agent capable of universal application wherever we require safe and effectual
stimulus to the muscular structure of the uterus. I shall consider the uses of galvanism in the succes-
sive epochs of gestation and parturition, beginning with its use in the induction of premature labor.

The Use of Galvanism in the Induction of Premature jLabor. — In 1803, Herder suggested the use of electro-
galvanism for the induction of premature labor. In August, 1814, Drs. Horninger and Jacobi succeeded
in bringing on labor by the electro-galvanic apparatus after other means had failed. The application
was immediately followed by uterine action, and the child was born in an hour from tho commencement
of the operation. A successful case under the hands of Mr. Demsey is also referred to by Dr. Golding
Bird. My researches into what has been written on the subject have not been sufficiently minute to
enable me to say that no other similar cases have been recorded. In January, 1851, I myself had an
opportunity of testing the efficacy of this agent.

Case 3. — I have already referred to this case for the purpose of illustrating tho effect of contraction oj
the uterus upon the fetal circulation. The result, although perfectly satisfactory, was by no means bo
•peedily accomplished as in the case of Horninger and Jacobi. I had previously endeavored to bring
on labor by puncturing tho membranes, and inserting a sponge-plug in the cervix uteri. This proceeding

712

AMERICAN ECLECTIC OBSTETRICS.

Galvanism is especially advantageous, as a general stimulant, in all those cases
in which the vital powers are extremely depressed from loss of blood. Its beneficial
effects are to be observed in the change of the countenance, restoring an animated

was followed by no symptom ftf labor. On the 23il of January I applied the galvanic battery for half an
hour, placing one pole on either side of the uterus. Immediately after commencing the shocks the blad-
der was irresistably emptied, to the evident annoyance of the patient. The womb was felt to become
hard, and the patient herself was sensible of contractions and increased movements of the fetus. The
contractions did not continue on the cessation of the galvanism, and I therefore repeated the application
on the 24th and 26th, for about an hour each time. On the 2Gth a "show " took place. On the evening
of the 27th, slight pains were felt ; the cord was presenting, a small loop coming through the os uteri,
which was now dilated to the size of a shilling, but feeling rigid. She had had rather copious Hooding
in the day time, but it had stopped. The head was felt lying on the pubes in front of the os uteri, the
cord coming down in the free space behind it. On the morning of the 28th, the galvanism having been
applied at intervals all night, the pains had increased. I have already mentioned how the galvanism
increased or originated contraction. At nine A. M. the child was born. It was apparently not more
than six months old. The patient had certainly reckoned falsely. The child's heart was pulsating ; tho
chest made three or four convulsive heaves, at which the mouth opened, but no air seemed to enter ; the
lungs refused to expand ; the walls of the chest were drawn in toward the spine. I endeavored to excite
respiration by the galvanic apparatus, but, although I could at will cause a respiratory effort, the child
was evidently too immature to live. The womb contracted favorably, and the placenta being withdrawn
was found healthy. The patient recovered without a bad symptom.

The excellent effect of galvanism in this case led me to recommend the use of tho same agent to my
friend Mr. Mansford, who has favored me with the following account :

Case 1. — " Tho lady whoso case led me to attempt the induction of premature labor, was in the 41st
year of her ago, and the thirtieth week of her fifth pregnancy. On the 8th of November, 1852, having
ruptured the membranes, I introduced one wire of the apparatus within the os uteri, and placed the
other in concord with the spine. From tho one introduced into the uterus I had removed the brass
handle, and twisted the wire upon itself so as to form a loop sufficiently curved to insure its remaining
6teadily in its proper place. I also carefully enveloped a considerable portion of this wire with lint, as
well to protect the vagina from the twisted portion and extremity, as to prevent the galvanic current
from being diverted from the uterus. I then increased its power until it produced 'the most severe
cutting pains in the loins,' ' great bearing-down,' and ' a dreadful commotion in the womb.' These were
my patient's own expressions. The operation was repeated on the 9th and 10th, each morning for half
an hour : the effect, however, had not been as yet altogether satisfactory, as I had not been able to main-
tain a continuous action ; but on the fourth morning, viz., tho 11th, I remedied this defect, and kept up
a continuous current for three-quarters of an hour, when my patient begged me to desist, which I did,
and determined to wait a few days to see if this would accomplish the desired effect. Happily, on the 14th,
without any further interference, labor commenced, and terminated within four hours, in the birth of a
living child, and not a single untoward symptom occurred spontaneously. It was altogether a most
satisfactory case."

The foregoing results are directly at variance with tho opinion of Dr. Golding Bird, who says : " The
result I have arrived at is, that this agent, like the Ergot of Rye, and perhaps other ecbolic remedies,
generally fails to develop uterine action de novo. . . . Hence, though I believe it will generally fail
to induce premature labor, it will as generally succeed in stimulating the uterus to vigorous contraction
after labor has actually commenced.' In weighing this negative opinion, it should, however, be
observed, that tho latitude of qualification implied in the word " generally " deprives it of all precision of
meaning.

It would lead me beyond my present purpose to discuss the relative advantages of galvanism and the
douche recommended by Dr. Kiwisch, and other methods. I will simply remark, that whatever method
be determined upon for the purpose of bringing on labor, the stimulating property of galvanism upon
the uterus will be a most useful adjuvant.

I will briefly refer to the great superiority of this method over tho use of Ergot of Rye. An unexpected
obstacle to the expulsion of the fetus may arise after the administration of Ergot ; there is, consequently ,
danger of rupture of the uterus. How, for example, can we foretell that the child will not be driven
into the pelvis in a transverse position ? Secondly, there is the great improbability that the child will
be born within any reasonable period after the administration of Ergot ; many doses are required ;
there is the risk of ergotism to the mother ; and the peril to the child rises in proportion to the amount
of Ergot given ; moreover, it is extremely uncertain whether the Ergot will act at all. '

Tlie Use of Galvanism in Inertia during the First and Second Stages of Labor. — I will now illustrate the
effect of galvanism in lingering labor from uterine inertia. An interesting case of this nature is
recorded by Mr. Cleveland, which was brought to a close within fifteen minutes after_the use of the electro-
galvanic apparatus had been commenced. Mr. Houghton also relates four cases of arrested labor from

MATERIA MEDICA.

713

expression; in its influence on the heart and arteries; in changing the character of
respiration; and its warming influence on the general surface. I have several times
observed, in cases in which other powerful stimulants have failed to produce any bene-
ficial effects, the most decided advantages accrue after its application.

atony of the uterus, brought to a successful termination by the agency of galvanism. In three of these
Ergot had previously failed.

In a similar case I have myself experienced the like good effect, but I prefer citing the following
account supplied to me by my friend Dr. Mackenzie :

Case 5.—" I was sent for, one morning, to a young woman who had been admitted in labor at the Pad-
dington Infirmary, and on examination I found that the head presented. Although she had been severa
hours in labor, the os uteri was but little dilated. I saw her in the course of the same afternoon, but still
found very little dilatation. At ten P. M. but little progress had been made. I now determined to try
the effect of galvanism, and applied one pole of a single-current machine to the spine, and the other, by
means of Radford's director, to the neck of the uterus. The current was from time to time intermitted,
and uterine action of a vigorous character was excited. In about an hour a fine living child was born.
So vigorous were the expulsive efforts during the passage of the head through the os externum, that I
was obliged to take particular pains, to prevent rupture of the perineum. The impression left on my
mind by this case was, that galvanism should not be employed except very cautiously in primipara-, or iu
any other instance in which the perineum is rigid or imperfectly developed."

Galvanism may also be usefully employed in many cases of hemorrhage before the birth of the child.

A judicious application of this agent may, in many cases of arrest of the head from inertia, obviate
the necessity of resorting to the use of the forceps.

The Use of Galvanism in the Third Stuce of Labor, and in Hemorrhage. — We possess a greater amount o
evidence of the value of galvanism in the third stage of labor. Dr. Eadford has contributed many
valuable observations, exemplifying the power of galvanism in exciting contraction of the uterus in
cases of post-partum hemorrhage. These are too well known to require to bo cited. Mr. Houghton has
added other cases which occurred under his own observation. The only instance I will adduce here, iB
one which cocurred recently to Dr. Mackenzie.

Case 0. — " The patient had been upward of forty-eight hours in labor, under the care of Dr. Keogh,
who called in Mr. Clark, by whom I was sent for. When I saw the patient, uterine action had entirely
ceased, and I found, on examination, that the head was impacted in the pelvis, the face presenting with
the chin to the left cotyloid cavity. As the patient was exhausted, an opiate had been given, and as she
was disposed to sleep, we agreed to meet again in some hours, and if uterine action did not return, to
deliver by the forceps. At the appointed time no return of uterine action had taken place. I applied
the forceps ; the operation was accomplished with extreme difficulty, and the woman was delivered of a
fine, large, living child. I left the patient shortly afterward, but the next day, on meeting Dr. Keogh
and Mr. Clark, I learned that great apprehension had been felt throughout the night as to the occurrence
of hemorrhage, inasmuch as the utarus had remained flaccid and uncontracted, and at the time of my
visit it reached above the umbilicus, and was very soft and flabby. I proposed galvanism, and applied
one pole to the spine and the other to the neck of the uterus, occasionally intermitting the current.
This was done for half an hour, and evident uterine action was excited, the uterus becoming harder and
smaller, and on removing the poles two large coagula were expelled. The next day the uterus was more
contracted and smaller, and no hemorrhage had occurred. Galvanism was again used for half an hour
The uterus certainly contracted [under its influence. The following day no hemorrhage had occurred,
and the condition of the uterus was such as not to require any further recourse to the agent. Th
woman from this time recovered iu a most favorable manner." Dr. Mackenzie adds tho following
remarks in which I entirely concur : " It appears to me that the results of galvanism in this case were
highly satisfactory, because coagula retained in the uterus, from atony of tho organ, are not only cal-
culated to occasion hemorrhage, but by undergoing a species of putrefactive decay, to give rise to fever
and all the consequences of vitiation of the blood. Under such circumstances, I have known the hand
forcibly introduced into the uterus many days after labor for the removal of such coagula with very
disastrous results— results which this case shows may be obviated by having recourse to galvanism.

Other Uses of Galvanism in Obstetric Practice.— There is another case of not unfrequent occurrence in
Obstetric practice, in which galvanism may bo of eminent service— temporary paralysis of the bladder
following delivery. A case 1 have already related illustrates the power of galvanism in causing contrac
tion of the bladder. Drs. Goodwin and Radford describe an interesting case, in which the catheter was
employed two or three times a day, and could not be dispensed with. On Dr. Coodwin's suggestion, gal-
vanism was tried, and the first application proved successful.

I would especially recommend the use of galvanism in those cases in which the action of the uterus
has been unfortunately paralyzed under the influence of chloroform. In such cases, I believe no other
stimulus that can be applied will answer with equal certainty or efficiency.

46

714 AMERICAN ECLECTIC OBSTETRICS.

V

I have never observed that the child, in utero, has been injured by its use, which
gives it a great advantage over the administration of secale cornutum, which, in many
cases, is destructive of it. "This drug is liable to great deterioration: its operation
is not always certain, its failure depending sometimes, perhaps, on its inert qualities,

I am also sanguine as to t i value of galvanism, in exciting respiration in asphyxiated children.

There is another class of cases in which galvanism promises to be of the greatest service. A most
Interesting case has been recorded, in which Dr. Tyler Smith was enabled to produce expansion of the
neck of the uterus, and to bring an intra-uterine polypus into view, so as to admit of the application of
a ligature, by the application of galvanism, after Ergot had failed. I have also employed it with success,
for the purpose of causing the expulsion of hydatids. This case occurred in connection with my col-
league, Mr. Forbes, and I will relate so much of the account, as bears on the the question before us.

Case 7. — Ann W., aged 42, had had eight children and three abortions. She applied to Mr. Forbes, on
the 17th of June last, having anasarca of the legs. Two months before, she suffered a burning pain in
the region of the womb. She had menstruated up to Christmas last. Since that date there had been a
little hemorrhagic discharge at intervals. For the last month there has been a continued discharge of
colored fluid. Her health is much impaired, and her strength lowered. On the 18th while in bed, she
felt a vaginal discharge, and on getting up, passed a large quantity of blood. The pulse was weak,
thready, 103; face blauched ; headache intense. No pain preceded the hemorrhage. There was a tumor
in the seat of the pregnant womb, extending more to the right side, and reaching to the umbilicus; it
was firm and elastic, tender on pressure, which did not bring on labor-pains. The os uteri was the size
of a shilling, and rigid. No placental murmur or sounds of fetal heart heard. The breasts were quite
flaccid. Os slightly expanded toward the afternoon. A dead fetus, or some diseased condition of the
ovum was suspected. In consultation, Dr. Barnes suggested galvanism, to cause contraction ; this had
the desired effect, and Dr. Forbes was enabled to bring down a bunch of hydatids. The vagina was then
plugged and the abdomen bandaged. The disposition to contraction thus given, more hydatids were
afterward passed. Tincture of Ergot of Kye was then given in small doses. Early on the morning of
the 19th, the patient passed a large mass of hydatids, which was expelled suddenly with a pain like that
of labor. She was quite exhausted with loss of blood and previous disease ; symptoms of inflammation
appeared, and she 6ank the same night. The post-mortem examination revealed a large fibrous tumor
in the walls of the uterus, and an advanced stage of granular degeneration of the kidney.

In such a condition of the uterus and the patient, none of the ordinary means of exciting contraction
could have been employed with equal safety and advantage. The necessity of inducing contraction to
expel the contents of the womb and arrest the hemorrhage was obvious, and the utility of galvanism in
accomplishing this was manifest. I am disposed to regrtt that the galvanism was not more freely used.
The expulsion of the hydatid placenta might have been hastened.

It is beyond the strict scope of this paper, but I may be permitted to refer to the advantages attending
the use of galvanism in amenorrhea, hysteria, and other diseasi s of females, advantages which have been
clearly established by Dr. Golding Bird, Dr. Gull, and others. The stimulating influence of galvanism,
is well worthy of trial for the purpose of exciting, the lacteal secretion.

Mode of Applying Galvanism.— 1 have now gone through a series of illustrations, affording evidence of
the use and value of galvanism, in most of the forms of labor characterized by defective uterine action,
and in other cases whera the indication is to excite the contractile property of the uterus. I will con-
clude this paper with a brief description of the mode in which this powerful agent should be applied,
and a summary of the advantages it especially possesses in obstetric practice over the Ergot of Kye.
The ordinary electro-magnetic apparatus in use for medical purposes is, I believe, the best form that can
be employed. The principal of this apparatus consists in the induction of magnetic currents, by a cur-
rent of electricity, and the production of a rapid succession of feeble shocks by continual interruptions
to the current. I have observed that tho uterine contractions are always provoked at the break and
renewal of the circuit. Repeated 6hocks act as a far moto effectual and certain stimulus to uterine con-
tractility than a continued current. It is probably through inattention to this fact, that some practi-
tioners have failed in effecting contraction of the uterus by means of galvanism. As to the mode of
applying the poles, I do not think it necessary to apply one over the spine, and the other to the neck of
the uterus, as is usually done. I have found the application of the disks, covered with thin flannel
moistened in water, one on either side of the abdomen over the uterus, much more convenient, and quite
as effectual. The practice of applying one pole over the spins, and the other to the neck of the uterus,
further seems to me to be based upon an erroneous view of the mode in which galvanism acts upon mus-
cular fiber. When the poles are thus applied, one to the spino and the other to the cervix uteri, it is
doubtful whether the ensuing contraction of the uterus is due to primary excitation of tho spinal mar-
row. It is proved by the experiments of Mattoucci, and it is confirmed by general observation, that
galvanism acts directly vpon the muscular fiber, stimulating it to contraction. It is clear that this direct
action can bo as effectually obtained by passing the shocks through the uterus, by placing tho poles on

MATERIA MEDICA.

715

but frequently on a constitutional idiosyncrasy which resists its powers. There nre
organic states which forbid its use: when the os uteri is undilated or undilatable, the
child being still alive, it ought not to be administered. If in such a case it induces a
powerful tonic contraction of the uterus, it destroys the child. We can not control or
confine its action, and therefore it is totally unsuitable to cases in which we only want
a limited effect. Again, if exhaustion is an element in the case, it is wholly inappli-
cable, as we ought not to adopt any means which tend further to depress the vital
powers. The powerful and sanitary influence of galvanism was most decidedly
obtained in the preceding case" (referring to a case to which these remarks were
appended), "and the great advantage of this agent is, that its effects may be carried
to any degree, from first only exciting the uterus so to contract that its diameters are
lessened, and that its tissue comes to be applied to the body of the child. These, how-

either side of the abdomen. I would not be understood to affirm, that this immediate action of galvanism
upon the muscular fiber, is its sole mode of action, but that it is the primary and essential one : this pri-
mary peristaltic action commenced, the secondary and tertiary diastaltic, emotional and voluntary reac-
tions upon the uterus follow. The duration of the application must depend upon the requirements of the
case. It is often found that nothing but a primary excitation is wanted, and that this being suppliod,
the uterus will go on contracting spontaneously. In those cases where it is required to originate uterine
contraction, as in the induction of premature labor, several applications of an hour's duration will be
necessary. The uterus can not be roused to perfect action before the appointed time, without repeated
stimulation.

The Special Advantages of Galvanism, as an Agent for Producing Uterine Contraction. — Among the advan-
tages of Galvanism more especially worthy of attention are —
1st. The simplicity of the operation.

2d. The extensive range of cases in which it may be successfully employed, rendering the electro-mag-
netic apparatus a desirable addition to the armamentarium of the obstetric practitioner.

3d. The perfectly manageable character of the agent. Its action may be broken off and renewed at
pleasure. The moment we think the uterus is acting too powerfully under its use, we may iustantly
withdraw the exciting agency, and leave the uterus to the ordinary physiological stimuli, which seldom
impel the organ to undue activity. It moreover admits of easy regulating ; both the strength and dura-
tion of this agent are completely under our command. We have it in our power to imitate, in a remark-
able manner, the natural pains both as to intensity and intermission. Ergot has neither measuro nor
certainty. \

4th. Its peculiar appmpriateness and efficacy in cases of extreme exhaustion of the system, where
deglutition is difficult or impossible, or where the stomach rejects everything; where any other mechani-
cal application to the uterus is dangerous, or inconvenient, and especially where the introduction of the
hand into the uterus would be likely to be attended by injury or even a fatal result. Indeed, it may be
truly said, that in cases of extreme exhaustion, galvanism is the last resource left to us. The galvanic
stimulus can be applied, when everything beside is out of the question. The uterine muscular fiber will
respond to this stimulus, when the nervous system is utterly prostrate, when the heart has ceased to
beat, when the patient is moribund or even dead.

5th. Galvanism is less exhausting to the system, than Ergot or most other means of exciting contrac-
tion. It acts directly upon the uterine muscular fiber, and scarcely taxes at all the general powers
of the system.

6th. It does not necessarily preclude or supercede the use of other remedies, tending to fulfill the same
indication. — Lancet, Kov. 12, 1853, p. 45G.

Db. Mackenzie bore ample testimony to the correctness of Dr. Barnes' conclusions. He himself had
been for some time engaged in testing the use of galvanism in cases of uterine diseases as well as in
obstetric practice. He believed that there were four classes of cases, in which galvanism might be usu-
ally employed — 1st, for the induction of premature labor, as Dr. Barnes' cases proved ; 2d, in the various
forms of inertia uteri, during labor ; 3d, in placenta prsevia ; in this condition, the blood which he
believed escaped from the uterine arteries, could in no way be so effectually restrained, as by galvanism,
which he believed would speedily develop the action of the uterus ; 4th, there was another series of cases,
of various forms of passive hemorrhage and leucorrhea. He related the case of a patient who had been
delivered five weeks : for the first eighteen days she had been free from hemorrhage ; hemorrhage had
then set in ; she became blanched, and exhibited evident marks of excessivo loss of blood ; this degene-
rated into passive hemorrhage. There was no disease of the cervix uteri. He applied galvanism ; the
hemorrhage stopped, and on the next day it had not returned ; the application was repeated. He wa»
co'nfident that in galvanism we possessed an agent worthy of our further investigation."

716

AMERICAN ECLECTIC OBSTETRICS.

ever, may be at pleasure increased, so as to accomplish the expulsion of the child and
placenta. The gradual changes produced upon the uterine tissues were admirably
seen in the foregoing case, and also its great power developed by its continued appli-
cation— to arrest the discharge, expel the child and the placenta, and leave the organ
gafe from the occurrence of post-partum flooding. — Extracted from a case, detailed in th;
proceedings of the local branch of the Provincial Medical and Surgical Association, 1847.

In the above-named case, I used the poles extcimally, and have before this, and ever
since adopted this mode of application. — Lancet, Nov. 26, 1853,/). 500.

The Galvanic Cautery has been employed by Mr. Ellis in the treatment of uterine
disease :

"The instrument he employed was a good-sized silver catheter, straightened out,
with the end cut off, which formed the body of the instrument. It was then slit open
at the upper end and broached, so as to form a socket for the porcelain cauterizer, and
also to allow the internal wires to pass out. AVithin the catheter are placed the two
conducting wires, insulated, they being at one end connected with the wires of the
battery, and at the other with a piece of platinum wire, which is coiled round the
porcelain cauterizer. The battery employed is Groves', of four or five cells, and of
these, two are required to heat the porcelain to whiteness, which degree of heat is
essential. From this simple contrivance the instrument derives its principal value,
the heat being thus both intense and permanent. When ready for use it is entirely
under the control of the surgeon, a matter of vast importance in its application. The
patient to be operated upon should be in the usual obstetric position, and the batteries
and wires concealed from her, so that she should not have any idea of the nature of
the remedy. A good light and speculum are essential, and the speculum best suited is
the common circular glass one, or one of glass coated with gum-elastic. Neither the
two-bladed metallic nor the conical glass forms are at all suited; the former because
it allows all the heat from the blades of the speculum to be concentrated on those por-
tions of the vagina which bulge between them, and the latter because it is liable to be
easily expelled by the vagina. A full view of the os and cervix uteri having been
obtained, the os should be cleansed with a piece of cotton or wool, and when the cau-
tery has become intensely heated, it should be steadily introduced and quenched in
the diseased tissue, the duration of the application and the depth of its introduction
depending upon the effect required. The eschars thus produced are marked with a
whitish-yellow border, and the cervix often visibly contracts under the application of
the cautery. The author insisted upon heating the porcelain to whiteness, otherwise
slight hemorrhage may occur, from the instrument dragging off a portion of mucous
membrane, which invariably adheres to the instrument under such circumstances; the
surgeon should also remember that the degree of the eschar is entirely under his con-
trol. He then stated that the cases where it was applicable were those of induration
of the os and cervix uteri, of ulceration of the os, and in prolapsus uteri, and also in
prolapsus of the anterior wall of the vagina." — Lancet, Nov. 26, 1853, p. 503.

GELSEMINUM SEMPERVIRENS.

YELLOW JESSAMINE.

This plant, is common to the Southern States, the root of which possesses sedative,
relaxing, and antispasmodic properties, and is, undoubtedly one of our most valuable
agents. It is employed with success in all febrile and inflammatory forms of disease,
in cases of nervous irritability, convulsions, etc. In obstetrics it has been effica-

MATERIA MEDICA.

717

ciously employed in dysmenorrhea, abortion, to allay the nausea and vomiting of
pregnancy, or of labor, in gastrodynia, cramps, and odontalgia during pregnancy, in
rheumatism of the uterus, rigid os uteri, hour-glass contraction, retained placenta,
puerperal fever, puerperal convulsions, etc. As I have already alluded to its uses in
these various conditions, under their appropriate headings, I will not repeat them here
but refer the student to them, as well as to the agents which may be given to counter-
act its influence upon the system, when too powerful, on pages 335, 336.

Although, at first, in consequence of the many reports in circulation relative to the
dangers of this article, it was given with great caution and reserve, yet, at the present
time, it is used pretty extensively by all our practitioners, it having been found that
the dangerous accounts related of it were very much exaggerated, and that when given
with the same degree of prudence and discretion as would be exhibited in the admin-
istration of Morphia, Belladonna, Strychnia, Digitalis, Aconite, and other sedatives or
narcotics, it forms a very useful and important medicine, incapable of effecting any
injury upon the system.

The effects of this agent, when the system is properly under its influence, are,
clouded vision, double-sightedness, inability to open the eyes, with muscular prostra-
tion of the whole system; these symptoms gradually pass off, leaving the patient in a
few hours, refreshed and completely restored. As a general rule, so soon as the heavi-
ness or partial closing of the eyes is induced, the medicine should be administered
no longer; there may be cases, howevei-, in which one or two subsequent doses may
be given with safety and advantage, as in puerperal convulsions.

It is administered in the form of saturated tincture, and is frequently combined
with the saturated tincture of Aconite, or Black Cohosh, for the purpose of facilitating
its influence in lessening arterial action, allaying pain, relieving severe and obstinate
cough, etc.

The dose of the tincture is from ten to sixty drops, in a wineglass half full of water,
and which may be repeated every hour or two, according to the character of the dis-
ease, and the susceptibility of the system to its influence.

Sometimes, especially in persons of delicate habits, or those who are easily influenced
by medicines, it will be found more advantageous to give the remedy in small doses,
as ten, fifteen, or twenty drops, and repeat them at shorter intervals.

Its internal administration is said to be contra-indicated in congestive fever, where
there is excessive prostration of the muscular or nervous system, and where there
exists a determination to the brain or other vital organ. I must observe, however,
that although I have no doubt of the correctness of this statement as relates to ner-
vous or muscular prostration, I am inclined to doubt its correctness concerning the
other affections referred to, no satisfactory evidence having yet been presented of its
injurious action in these instances, but rather the reverse. (See Author's American
Dispensatory — Gelseminum.)

GERANIUM MACULATUM.

GERANIUM.

An indigenous, perennial plant, known also by the names, Cranesbill, Croivsfoot, etc.
The root is a powerful astringent, and has been successfully used in powder or decoc-
tion in menorrhagia, diarrhea of pregnant females, summer complaint of children,
and aphthous ulcerations of the mouth. As a local application it is beneficial in leu-
corrhea, gleet, bleeding piles, and aphthae. The decoction is made by boiling the root
in water or milk, and its dose is from one to two fluidounces, three, four, or five times
a day. Dose of the powder is from ten to thirty grains.

718

AMERICAN ECLECTIC OBSTETRICS.

GERANIIN, is the concentrated extract of the root of Geranium. It possesses the
astringent properties of the root in an eminent degree, not causing any dryness of the
mucous surfaces with which it comes in contact, in which respect it differs from Tan-
nic Acid. It has been employed with benefit in diarrhea, dysentery, summer-complaint,
menorrhagia, colliquative diarrhea, etc. Combined with Capsicum and Ipecacuanha,
it appears to increase their efficacy in uterine hemorrhage. The dose of Geraniin is
from one to five grains or more, repeated as required; it may be given in syrupi
molasses, gruel, water or port wine.

GOSSYPIUM HERBACEUM.

COTTON.

A well-known annual plant, the recent inner bark of the root of which is emmena-
gogue, parturient, and abortive. A tincture of the recent bark in spirit of Nitric
Ether, and administered in doses of from thirty to sixty drops, three, four, or five times
a day, has produced the most decided and prompt relief in amenorrhea, owing to a
torpid condition of the uterus, or a mere derangement of its functions not connected
with disease of other parts. It has likewise proved efficacious in cases of recent
dysmenorrhea.

During labor, it will be found to excite uterine contractions when these are weak,
and inefficient; and I have successfully used it in a few cases of uterine hemorrhage,
in combination with Ergot and Cinnamon. {Page 490.)

A strong decoction of the recent bark may be made by adding four ounces of it to a
quart of water, and boiling down to a pint ; the dose is one or two fluid ounces every
twenty or thirty minutes. That this decoction will produce abortion is an undoubted
fact, and it was much used by the female blacks of the South for this purpose, who,
generally, took but one dose, about a pint of the strong decoction. It appears to effec^
the desired result without any injury to the general health. {Page 612.)

An extract is made from the recent bark, which forms an excellent emmenagogue,
and which may be used in amenorrhea and dysmenorrhea in combination with Bella-
donna and Quinia. It may be advantageously added to Caulophyllin, Cimicifugin,
Senecin, etc., in the treatment of uterine affections. The dose of the extract is from
three to ten grains, three times a day.

HiEMASTASIS.

LIGATINO THE EXTREMITIES.

Hajmastasis, is a term applied to the retention of venous blood in the extremities by
ligatures. A handkerchief, or any suitable cord is to be tied around the upper part of the
thighs, and the arms, and then by means of a piece of wood or other hard substance,
is to be turned or twisted around so as to compress the veins sufficient to check the cir-
culation of blood in them; care must be taken, however, not to check the circulation in
the arteries, which may be known by the action of the pulse. In a short time the arms
and legs will become much distended from an arrest of their venous circulation, and an
amount of blood may thus be removed from the trunk and retained in the limbs, which the
most heroic practitioner dare not remove by the lancet. Should the patient faint while
under the influence of this operation, promptly loosen or remove the ligatures; if he be

MATERIA MEDICA.

719

plethoric and of firm, vigorous constitution, he must be reduced by cathartics, diuret-
ics, or sudorifics, and be under the influence of some mild nauseant, at the time of the
operation.

This mode of reducing the amount of blood in the trunk is found very useful in ute-
rine hemorrhage, puerperal convulsions, placenta prscvia, in all operations where the
consequences of uterine hemorrhage are to be feared, and whenever it is deemed advi-
sable to lessen the amount of blood in the head and trunk, without injuring the system

HEDEOMA PULEGIOIDES.

PENNYROYAL.

A well-known indigenous annual plant, which possesses diaphoretic and emmena-
gogue properties. The warm infusion, used freely, will promote perspiration, restore
suppressed lochia, and excite the menstrual discharge when recently checked ; it ia
often used by females for this last purpose — a large draught being taken at bed-time,
the feet having been previously bathed in warm water for fifteen or twenty minutes.
A gill of brewer's yeast added to the draught is reputed a safe and certain abortive.
The oil is sometimes employed for the crimnal purpose of inducing abortion, but it is
dangerous.

HELONIAS DIOICA.

HELONIAS.

Also known as False Unicornroot. It is an indigneous, perennial plant, the root of
which possesses tonic properties. It also appears to exert an influence upon the
reproductive organs, gradually removing any derangement of their functions, and
giving to them tone and vigor. It has been advantageously used in leucorrhea, amen-
orrhea, dysmenorrhea, and in cases where there is a tendency to repeated and succes-
sive abortions. A medicated wine made of two ounces of Helonias, and one, each, of
Pleurisy-root, and Blue Cohosh, to a quart of Wine, and given in wineglassful doses
three times a day, has been found a superior remedy in many forms of uterine disease.
The dose of the powdered root is, from twenty to forty grains, three times a day; of
the decoction, from two to four fluidounces ; of the alcoholic extract, which is an ele-
gant preparation, from two to five grains. Practitioners must not confound this root
with that of the Aletris Farinosa, for which it is frequently mistaken.

HEUCHERA AMERICANA.

ALUMROOT.

An indigneous, perennial plant, the root of which is powerfully astringent. In decoc-
tion with equal parts of Goldenseal and Blue Cohosh, it has proved beneficial in the
diarrhea of parturient women, in diabetes, and in bleeding-piles, and as a local appli-
cation in nursing sore-mouth, aphthous sore-mouth, and leucorrhea. Equal parts of
Alum root and Black Cohosh in decoction, forms a valuable local application in excori-

720

AMERICAN ECLECTIC OBSTETRICS.

ation of the cervix uteri and also in vaginal leucorrhea. Internally, an aqueous
extract will be found a very eligible form for administration. The dose of the decoc-
tion is from one to two tablespoonfuls three or four times a day ; of the aqueous extract,
from two to four grains.

HUMULUS LUPULUS.

HOPS.

A well-known plant, the cones or strobiles of which are extensively employed in med-
icine, steeped in hot water or vinegar, as a fomentation in inflammatory and painful
affections, as in pleurisy, pneumonia, gastritis, enteritis, painful swellings or tumors,
etc.; sometimes they are beneficially combined with other articles, as Boneset, Tansy,
Stramonium, and several bitter herbs. In cases of wakefulness, a pillow stuffed with
Hops has long been a popular remedy for procuring sleep. Two parts of Stramonium
leaves and one of Hops, form a valuable application in salt-rheum, ulcers, and some
painful tumors. Hops are seldom employed internally, though ale, beer, and porter,
into the composition of which they enter largely, are frequently administered, for their
6timulating, tonic, nutritive power's, in cSses of debility with no inflammatory symp-
toms.

LUPULIN, is a yellow, granular powder, secreted by the Hop-scales, and which is
obtained by rubbing or thrashing the strobiles, and then sifting. As it rapidly loses
its virtues by keeping, it should either be formed immediately into a tincture, or elsa
the physician should supply himself with a fresh article every year. Owing to a neg-
lect of this matter, many practitioners do not employ Lupulin, considering it nearly or
quite inert.

Lupulin possesses tonic and hypnotic properties, allaying pain, relieving restless-
ness, and inducing sleep. It will likewise be found useful in after-pains, and to sup-
press sexual desires. In cases of wakefulness connected with nervous irritation, anx-
iety, or exhaustion, it will frequently be found valuable: its internal exhibition does
not derange the stomach, nor cause constipation, as is the case with Opium. The fol-
lowing preparation forms an excellent remedy in after-pains, and in nervous irritabil-
ity and wakefulness of parturient women :

R. Lupulin, twelve grains,

Caulophyllin,

Scutellarin, of each, six grains. Mix.

Divide into six powders, and give one every two or three hours. Or, instead of pow-
der, it may be formed into a similar number of pills. A mixture of oil of Chamomile
one fluidrachm, ethereal oil of Lupulin one fluidrachm and a half, Sulphuric Ether half
a fluidounce, has been found very useful in dysmenorrhea, and other painful affections
of the uterus, in doses of from thirty to sixty drops, every three hours: it will like-
wise be of service in nervous headache, and in cases of great nervous excitability.
The ethereal oil of Lupulin is'made by forming a tincture with Ether and Lupulin, fil-
tering, and allowing the Ether to evaporate spontaneously.
The dose of Lupulin is from two to ten grains, every one, two, or three hours, and

MATERIA MEDICA.

721

which may be given in powder, or in pill by merely rubbing it in a warm mortar until it
acquires a pilular consistance. The dose of the tincture is from one to four fluidrachms,
in mucilage or sweetened water.

HYOSCYAMUS NIGER.

HENBANE. .

A biennial plant, indigenous to Europe, but naturalized in the northern parts of
this country. The leaves and seeds are the parts used. In large doses they are power-
fully poisonous ; in small ones they are anodyne and calmative, and are much used for
allaying pain, soothing excitability, arresting spasms, and inducing sleep.

Henbane, unlike Opium, does not produce constipation, but has a tendency to act as a
laxative : hence it is frequently given as a substitute for Opium in cases where consti-
pation must be avoided, or where that drug disagrees. It may be exhibited in febrile
and inflammatory affections, neuralgia of the uterus, nervous headache, and in cases
of excessive nervous excitability. Added to Podophyllin, or other active cathartics, it
will prevent tormina without impairing their energy.

In combination with Lupulin and Caulophyllin, it will frequently be found very
efficacious in after-pains, and nervous irritability of the puerperal female. It is usually
administered in the form of tincture, the dose of which is from half a fluidrachm to
two fluidrachms, as often as required. The alcoholic extract is also an elegant form for
administration: when properly prepared, it contains all the medicinal virtues of the
plant, and may be given in doses of one-fourth of a grain two or three times a day,
gradually increased to one or two grains, or until the desired influence is obtained.
The fluid extract of this remedy is frequently prescribed in doses of from ten drops to
a fluidrachm. It forms a durable and efficient preparation.

HYPERICUM PERFORATUM.

ST. JOHNSWORT.

An indigenous, perennial plant, the tops and flowers of which are the parts em-
ployed. They possess astringent, sedative, and diuretic properties, and have been
successfully given in diarrhea, jaundice of children, hysteria, menorrhagia, and in
depressed nervous conditions. Locally applied, in fomentation or in the form of an
ointment, they are useful for dispelling hard tumors, caked breasts, bruises, ecchy-
mosis, ulcers, etc.

I have successfully employed this article in congestion of the cervix, ecchymosis of
the cervix, and erosion of the cervix. The tops and flowers having been coarsely
bruised and infused in hot water, the infusion may be applied directly to the cervix,
in the same manner as mentioned for a similar application of Arnica flowers on page
689. Or they may be macerated in Glycerin, or in Sweet Oil, and be applied in the
manner just stated for the infusion.

From the happy results obtained from these agents in the diseases named, in my
own practice, I can not too highly recommend them to the profession; it is to be hoped
that others will use them, and fully test their virtues in similar affections.

The dose of St. Johnswort, in decoction or infusion, is one or two fluidounces every
hour or two.

722

AMERICAN ECLECTIC OBSTETRICS.

IODINIUM.

IODINE.

This is an elementally, non-metallic body, principally obtained from sea-weeds. It
possesses, in medicinal doses, alterative, diuretic, and emmenagogue properties, and
is much employed in scrofula, bronchocele, syphilis, enlargement of the external
absorbent glands, enlargement of the liver and spleen, breasts and uterus; in ovarian
tumors, leucorrhea, amenorrhea, and dysmenorrhea. In chronic diarrhea and dysen-
tery, obstinate cholera-infantum, and obstinate diarrhea of puerperal females, I have
found the following a superior remedy:

Tfc. Iodine, twelve grains,

Geraniin, two drachms and two scruples,
Sulphate of Morphia, one grain,

Simple Syrup, a sufficient quantity to form a pill-mass. Mix.

Divide the mass into eighty pills, of which one pill may be given to an adult, and
repeated every hour or two. The same pill will be found applicable to many uterine
diseases, by omitting the Geraniin and substituting Caulophyllin or Cimicifugin.
Thus prepared, it will be found of much value in leucorrhea, amenorrhea, and engorge-
ments of the uterus.

Iodine, when given internally to females, is apt to increase the quantity of the men-
strual discharge, and sometimes to multiply the periods of its appearance; if the
symptoms are not very severe or alarming, but little interference will be required, as
they will cease after a short time; but where this is demanded, a cessation of the use
of the remedy will most generally suffice.

I make extensive use of a preparation, in leucorrhea, amenorrhea, and other uterine
difficulties, made by adding two fluidrachms of the tincture of Iodine to fourteen flui-
drachms of the saturated tincture of Black Cohosh root. The dose is from twelve to
eighteen drops, in a small quantity of water, three or four times a day. Although the
dose of Iodine, in this mixture, is not very large, yet the agent will be found to exert
a prompt and most happy influence upon the disease.

The compound tincture of Iodine possesses all the medicinal virtues of the Iodine
and is at' present more generally employed than the simple tincture, principally
because it is less liable to decomposition. It is made as follows:

Jfc. Iodine, one drachm,

Iodide of Potassium, two drachms,
Alcohol, four fluidounces. Mix.

Dissolve the Iodine and the Iodide of Potassium in the alcohol. The dose of this tinc-
ture is five drops three times a day, gradually increased to thirty, if necessary. — A
preparation composed of Iodine fifteen grains, Iodide of Potassium thirty grains,
Glycerin one fluidounce, forms a very useful local application to ulcers around the os
uteri; I have found it to be exceedingly valuable for this purpose.

The dose of Iodine in substance, is half a grain two or three times a day : it should
be powdered, and made into pill-form by the addition of some inert substance; or, it
were much better to add Opium or Morphia to it, in order to lessen its irritative action
upon the stomach, and form into a pill with extract of Liquorice.

Dose of the simple tincture, from five to fifteen drops, two or three times a day.

MATERIA MEDICA.

723

IRIS VERSICOLOR.

BLUE FLAG.

An indigenous, perennial plant, the root of which possesses cathartic, alterative, and
diuretic properties. It may be administered with advantage in amenorrhea, and leu-
corrhea, either alone, or in combination with other agents which exert a direct influ-
ence upon the uterus. In obstinate affections of the reproductive organs, they may
be frequently rendered susceptible to the influence of the remedies administered, by
first salivating the patient, with a mixture composed of equal parts of Blue Flag root,
Mandrake root, and Prickly-Ash bark; of which, from five to ten grains may be given
every two or three hours (so as to fall short of catharsis), and which will act as a pow-
erful alterative, causing a copious salivation without rendering the breath offensive, or
injuring the teeth or gums. The dose of Blue Flag, in powder, is from five to
twenty grains, of the saturated tincture, from ten to sixty drops.

IRIDIN, the oleo-resinous principle of Blue Flag, possesses the active properties of
the root. Although not so prompt in its action as Podophyllin, yet 1 prefer it to that
article, when conjoined with Cimicifugin, in many diseases of the uterus. Any harsh-
ness of action of Blue Flag root, or of Iridin may be lessened or removed entirely, by
the addition of a few grains of Capsicum, or, Ginger, a half grain or a grain of Cam-
phor, or, two or three grains of Caulophyllin, or, half a grain of extract of Hyoscyamus.
Since the manufacture of Podophyllin, this agent has been unjustly neglected, and
probably on account of its slowness of action ; but by so doing, physicians deprive
themselves of a most valuable medicine. The dose of Iridin, is from half a grain, to
three or four grains.

JUNIPERUS SABINA.

SAVIN.

This is a well-known evergreen shrub, a native of Europe, and growing in this
country. The tops and leaves are the parts used. They possess emmenagogue and
abortive properties. A warm decoction is a popular remedy in some sections of the
country, for suppression of the menses. It is likewise said to be useful in Menor-
rhagia, and to prevent threatened abortion; but I am inclined to doubt such state-
ments. It should never be given when much general or local inflammation exists,
neither should it be used during pregnancy.

The oil of Savin, given two or three times a day, in doses of from ten to fifteen drops
on sugar, will, it is said, most certainly produce abortion; but it is a dangerous agent,
apt to violently affect the stomach and bowels, and produce an inflammation of these
organs terminating in death, as has been witnessed in many females who have taken
it with this criminal intent.

The oil, has likewise been combined with oils of Tansy, Pennyroyal, and Hemlock,
as an emmenagogue, in doses of from two to four drops; and in larger doses, to crim-
inally produce abortion, but it is seldom given for this latter purpose, without destroy-
ing the female, or causing some painful and annoying symptom, which remains
through life — Th) following tincture has been highly recommended in amenorrhea:
Jt. Tincture of Ergot,
Essence of Savin,
Tincture of Black Cohosh,

Tincture of Water Pepper, of each, one fluid ounce. Mix.
The dose is a fluidrachm, two or three times a day.

724

AMERICAN ECLECTIC OBSTETRICS.

In the administration of Savin, or its oil, too much care can not be observed, as it
may produce fatal results. The dose of the powdered leaves, is from five to fifteen
grains, three times a day; of the infusion, from half a fluidounce to two fluidounces.

The JUNIPERUS VIRGINIAN A, or Red Cedar, is sometimes used as a substitute
for the above, but it is less active.

KALMIA ANGUSTIFOLIA.

SHEEP LAUREL.

An indigenous shrub, the leaves of which possess sedative and astringent proper-
ties. They may be used in powder, or decoction, but the tincture is the best form for
administration. It will be found very valuable in febrile and in inflammatory dis-
eases, and hypertrophy of the heart, allaying all febrile and inflammatory action, and
lessening the action of the heart. It may be employed with efficacy in cases of abor-
tion caused by syphilitic taint, and may be given alone, or in combination with tinc-
ture of Black Cohosh, or tincture of Poke-i-oot.

In active menorrhagia, it has proved decidedly beneficial, by combining one part of
the tincture of Kalmia with four of the tincture of Cinnamon, and administering the
mixture in doses of from twenty to forty drops, every two or three hours.

In palpitation of the heart, connected with hypertrophy of that organ, prompt relief
will frequently be obtained from the following compound:

gr. Tincture of Musk,
Tincture of Kalmia,
Sulphuric Ether,

Essence of Cinnamon, of each, one fluidrachm. Mix.

The dose is from ten to thirty drops, three times a day.

The dose of Sheep-Laurel leaves, in powder, is, from ten to thirty grains, two or
three times a day; of the decoction, from half a fluidounce to a fluidounce; and of the
tincture, from ten to twenty drops. As large or improper doses will produce vertigo,
dimness of sight, great depression of the action of the heart, and cold extremities,
much care must be observed when using it; ceasing its use for a few days, or dimin-
ishing the dose, when these symptoms appear. Its poisonous effects are best overcome
by alcoholic stimulants, with counter-irritation to the spine and extremities.

KRAMERIA TRIANDRIA.

RHATANY.

A South American plant, the root of which is a powerful astringent. The tincture
has been used with much advantage in passive menorrhagia, leucorrhea, uterine
hemorrhage, and in the diarrhea of puerperal females. It is likewise useful in the
eummer-complaint of children. In uterine hemorrhage, it has been beneficially added
to other agents, as tincture of Ergot, tincture of Cinnamon, etc. The dose of the tinc-
ture of Rliatany, is from one to four fiuidrachms, repeated three or four times a day.
An extract is sometimes prepared from it and given in doses of from ten to twenty
grains.

MATERIA MEDICA.

725

LEONORUS CARDIACA.

MOTHERWORT.

A well-known exotic, but extensively growing in this country. The tops and leaves
are emmenagogue, nervine, antispasmodic, and, in some cases, laxative. It is most
commonly prescribed in warm infusion, in menstrual suppression from colds, and in
deficient or suspended lochia. In this last difficulty I have found it superior to any
other remedy.

The alcoholic extract possesses emmenagogue, nervine, and antispasmodic proper-
ties, and may be given in the nervous diseases of women, in painful affections peculiar
to females, in irritable habits, and in amenorrhea. It may be advantageously com-
bined with Asclepidin, Cimicifugin, Scutellaria, etc., in female difficulties. The dose
of the alcoholic extract is from three to six grains, every two, three or four hours; of
the decoction, from two to four fluidounces.

The leaves and tops steeped in hot water, may be used as a fomentation over the
abdomen, in suppressed or painful menstruation, and in suspended lochia.

LIGUSTRUM VULGARE.

PRIVET.

An indigenous shrub, the leaves of which are astringent. A decoction of them is
valuable in long-standing summer-complaints, in the diarrhea of puerperal females,
and as a local application in leucorrhea, ulceration of the bladder, and ulcers of the
mouth and throat. It is also useful in the chronic diarrhea, and obstinate summer-
complaint of children. The dose of the powdered leaves, is from thirty to sixty grains,
three times a day ; of the decoction, from two to four fluidounces.

LOBELIA INFLATA.

LOBELIA.

A well-known indigenous plant, the leaves and seeds of which are the parts used in
medicine. It possesses active emetic properties, but it is seldom used for this purpose
in obstetric practice; being more generally employed on account of its relaxant, seda-
tive, and antispasmodic influences. And for these purposes it is administered in the
form of the officinal preparation, compound tincture of Lobelia and Capsicum, the
formula for which is as follows:

Jfc. Lobelia,

Capsicum,

Skunk-Cabbage root, of each, in powder, one ounce,
Alcohol, one pint. Mix.

Macerate for fourteen days, express, and filter.

This preparation is a most powerful relaxant and antispasmodic, and is highly effi-
cacious in cramps, spasms, convulsions, tetanus, rigidity of the os uteri, hour-glass
contraction, etc. In convulsions and tetanus, it may be poured into the corner of the

726

AMERICAN ECLECTIC OBSTETRICS.

mouth, and repeated as often as necessary; generally, the effect is almost instantane-
ous. In rigidity of the os uteri, a fluidrachm administered by mouth, or double the
quantity by enema into the rectum, and repeated, if necessary, in fifteen or twenty
minutes, will be found to produce a state of softness and dilatability without the neces-
sity of using the lancet, so highly recommended by many authors. Used in this latter
mode, as an injection, it will frequently arouse the uterus to contract energetically,
without the use of Ergot or any other parturient agent.

The dose of the tincture is from half a fluidrachm to a fluidrachm every ten or
twenty minutes, or as often as the urgency of the case requires. In the hysterical
convulsions occurring during pregnancy, and in puerperal convulsions, a much larger
dose will frequently be required, as a tablespoonful, or half a fluidounce. Every
accoucheur should make this one of the principal remedies with which he provides
himself.

An infusion of Lobelia, made by digesting three or four drachms of the powdered
herb in a pint of boiling water, will be found very useful when used in injection, in
relieving and arresting the false pains frequently met with previous to labor; in over-
coming rigidity of the os uteri, as well as of the perineum ; in rendering the irregular
and spasmodic contractions of the uterus during labor, normal and active; and in
relieving the headache, and other premonitory symptoms of puerperal convulsions
which are sometimes met with. It will likewise be found to induce speedy delivery in
those instances where delay is owing to want of uterine nervous energy.

Lobelia may be used for many other purposes with advantage; as a nauseant and
expsctorant in croup, pneumonia, laryngitis, pertussis, catarrh, etc., for which purpose
it may be given in doses of from five to twenty grains. Sometimes it is combined with
Bloodroot, Senega, Squill, or other nauseants.

In the early stages of fever, it may be exhibited with benefit, as it relaxes the sys-
tem, modifies arterial excitement, produces diaphoresis, thus tending to equalize ths
circulation, and assisting the vital powers to eliminate morbid matters.

In the diseases of infancy, as cough, croup, pertussis, bronchitis, asthma, etc., the
compound tincture of Lobelia is much employed ; it is made thus:

Jt. Lobelia, herb, •
Bloodroot,

Skunk-Cabbage root,
Wild Ginger root,

Pleurisy-root, of each, coarsely powdered, one ounce
Alcohol, three pints. Mix.

Macerate for fourteen days, express, and filter.

This tincture may be used to produce emesis, or merely to nauseate; in croup, per-
tussis, and bronchitis its emetic influence should be first produced, and afterward only
its nauseating. As an emetic, it may be given in doses of from half a fluidrachm to
half a fluidounce, according to the age of the child, the above doses ranging between
those of six months old and ten years. It may be given in molasses, and should be
repeated every ten or fifteen minutes, until vomiting is produced, aiding its action by
the administration of warm water, warm infusion of Boneset, or Chamomile flowers.

As an expectorant, the dose is from five drops to sixty, given in some infusion of Elm-
bark, or flaxseed ; the bowels must be kept regular in all instances.

The oil of Lobelia, though sometimes prescribed internally, is better adapted for
external use, as, if care be not observed, it is apt to occasion inflammation of the

MATERIA MEDICA.

727

ptomach. In the cramps and painful affections of the extremities, during pregnancy,
as well as at other times, the following liniment will be found a valuable application :

]£. Oil of Amber,

Oil of Sassafras, of each, half a fluidounce,
Oil of Lobelia, a fluidraclim,

Ethereal oil of Capsicum, half a fluidrachm. Mix.

This may be applied to the affected parts, two or three times a day, and, if it proves
too severe, it may be reduced in strength by the addition of one or two fluidounces
of Olive oil.

Dose of the powder of Lobelia, as an emetic, from twenty to sixty grains ; of the
tincture,? from two to four fluidrachms.

MARUTA COTULA.

MAYWEED.

A well-known plant, the flowers of which are emetic, tonic, emmenagogue, and anti-
spasmodic. As an emetic it is given in warm infusion freely; as a tonic, the cold infu-
sion is employed in doses of from half a fluidounce to two fluidounces, three or four
times a day. The warm infusion is frequently used in recent amenorrhea, and with
decided efficacy. An aqueous extract may be made from the flowers, which will be
of service in the sick-headache of females, in convalescence from exhausting diseases,
in the anorexia of pregnancy, and as a tonic and antispasmodic, in all cases where these
influences are indicated.

The recent plant bruised and applied to the skin, will cause vesication, and the sores
heal readily.

The fresh leaves of Mayweed and Water Pepper, equal parts of each, bruised, and
moistened with a small quantity of Spirits of Turpentine, form a powerful epispastic.

MEL.

n O N E Y .

Honey is nutritious, antiseptic, diuretic, and demulcent, and is much used in urinary
and pulmonary affections, and as an addition to injections, lotions, gargles, etc. A
very excellent and palatable preparation for coughs, especially during febrile or
inflammatory attacks, is made as follows:

Honey,
Olive oil,

Spirits of Nitric Ether,

Lemon juice, of each, one fluidounce. Mix.

The dose is from half a fluidrachm, to a fluidrachm, to be repeated several times a
day, or when the cough is very severe.

A tincture of Honey-bees is highly recommended by some practitioners in diseases of
the bladder and kidneys, as well as in some uterine affections. It is prepared by

728

AMERICAN ECLECTIC OBSTETRICS.

placing a quantity of the living bees in a vial, agitating them roughly, so as to irritate
them, and while in this condition, cover them with alcohol; in a few days the tinc-
ture will be ready for use. The dose is five, ten, or twenty drops, repeated three or
four times a day. It is asserted that if employed too freely, or if its use be too long
continued, it will cause abortion in the pregnant female.

MITCHELL A REPENS.

PARTRIDGEBERRY.

An indigenous evergreen herb, which possesses diuretic, astringent, and parturient
properties. It is chiefly used for its tonic and alterative influence upon the uterus, and
is beneficial in all derangements of the functions of this organ, as amenorrhea, dysmen-
orrhea, etc. The squaws are said to drink a decoction of this plant for several weeks
previous to their confinement, for the purpose of rendering parturition safe and easy,
and which is undoubtedly effected through the tonicity imparted to the uterus by it.

It is principally employed in the officinal preparation, compound syrup of Partridge-
berry, or Mother's Cordial, which is prepared as follows:

$ Partridgeberry, one pound,

Helonias root,
High Cranberry^bark,
Blue Cohosh root, of each, four ounces.

Grind and mix the articles together; place the whole pound and three-quarters in a
convenient vessel, cover them with fourth-proof Brandy, and macerate for three days.
Then transfer the whole to a displacement apparatus, and gradually add Brandy, until
three pints of spirituous tincture have been obtained, which reserve. Then continue the
displacement with hot water until the liquid passes tasteless; add to this two pounds of
refined sugar, and evapoi-ate by a gentle heat to five pints ; remove from the fire, add
the reserved three pints of spirituous tincture, and flavor with essence of Sassafras, or
Wintergrccn.

This preparation is employed in all cases where the functions of the internal repro-
ductive organs of the female are deranged, as in amenorrhea, dysmenorrhea, menor-
rhagia, leucorrhea, and to overcome the tendency of habitual abortion. The dose is
from two to four fluidounces, three times a day. Pregnant females, especially those of
a delicate or nervous habit, will find it an advantage to take one or two doses daily, for
several weeks previous to parturition, as, by the energy it imparts to the uterine
nervous system, the labor will be very much facilitated ; beside which, it frequently
removes the cramps to which some females are liable during kthe latter weeks of utero-
gestation.

The following is highly recommended as a cure for sore nipples : Take two ounces of
the fresh herb Partridgeberry, add to it a pint of water, and make a strong decoction;
then strain, add as much good cream as there is liquid of the decoction, and gently
boil the whole down to the consistence of a soft salve. When cool it is fit for use. The
nipple is to be annointed with it every time the child is removed from the breast.

MATERIA MEDICA.

729

NEPETA CHTARIA.

CATNIP.

A common and well-known herb, the tops and leaves of which are carminative and
diaphoretic, when employed in warm infusion ; and tonic, when used cold. The warm
infusion is much used in febrile diseases as a diaphoretic, and to promote the action
of other diaphoretics, as well as to allay spasmodic action, and induce sleep; it has
also proved decidedly beneficial in amenorrhea, dysmenorrhea, nervous headache, hys-
teria, and nervous irritability, and as a carminative and antispasmodic in the flatulent
colic of children. The expressed juice of the herb, given in doses of a tablespoonful,
two or three times a day, is a superior remedy in amenorrhea, frequently restoring the
menstrual secretion after other means have failed. A fluid extract of Catnip, Valerian,
and Scullcap, forms an excellent remedy for the cure of nervous headache, restless-
ness, and many other nervous symptoms. The infusion of catnip may be drank as
freely as the stomach will permit, in all cases.

OLEUM TEREBINTHINvE.

OIL OR SFIRITS OF TURPENTINE.

This agent is emplo3*ed for various purposes: thus, from its influence in diminishing
excessive mucous discharges, it has been advantageously exhibited in chronic catarrh,
chronic diarrhea, chronic dysentery, chronic inflammation of the bladder, and leu-
corrhea, in which cases it may be given in doses of from five drops to half a fluidrachm
every three or four hours. In menorrhagia and uterine hemorrhage, it acts as a most
efficacious astringent, in doses varying from twenty minims to a fluidrachm, according
to the urgency of the symptoms, and repeated every hour or two, as required: it may
be given in Cinnamon-water, decoction of Rhatany, or other aqueous astringent prep-
aration. When used in the form of enema, it has proved successful in cases of amen-
orrhea arising from torpor of the uterine vessels, and in tympanitic distension of
abdomen. From half a fluidounce to two fluidounces .'may be suspended in half a
pint of water, or some mucilaginous liquid, by means of two yelks of egg, injected
into the rectum, and retained there for some time. One part of oil of Turpentine,
added to three or four parts of Castor Oil, forms an ordinary remedy for worms in
children.

Warren's Styptic Balsam, has been used with uniform success for a period of nearly
thirty years in the treatment of hemorrhages, requiring no confinement to the room,
nor any especial auxiliary treatment. In hemoptysis, epistaxis, hematemesis, and
menorrhagia, it affords prompt relief. It is made as follows : Place Sulphuric Acid,
five drachms by weight, in a Wedgewood mortar, and slowly add to it oil of Turpen-
tine two fluidrachms, stirring it constantly with the pestle; then add, in the same man-
ner, Alcohol two fluidrachms, and continue stirring until no more fumes arise, when
it may be bottled, and should be stopped with a ground-glass stopper. It should be pre-
pared from the purest materials, and when made should exhibit a dark but clear red
color, like dark-blood; but if it be a pale, dirty red, it will be unfit for use. After
standing a few days, a pellicle forms upon the surface of the balsam, which should ba
broken and the liquid below it used. If in well-stopped bottles, age does not deteriorate
it. The dose is forty drops, to be used as follows: Into a common-sized teacup put a
teaspoonful of brown sugar, thoroughly incorporate the forty drops by rubbing together,

47

730

AMERICAN ECLECTIC OBSTETRICS.

and then slowly stir in some water until the cup is nearly full, when it should be
immediately swallowed. The dose may be repeated every hour for three or four hours,
and its use should be discontinued as soon as fresh blood ceases to flow.

OSMUNDA REGALIS.

BUCKHORN BRAKE.

A beautiful indigenous fern, the root of which possesses tonic and mucilaginous
properties. It is very valuable in leucorrhea and other female weaknesses, and is
much employed in the treatment of rickets.

One root, infused for half an hour in a pint of hot water, will convert the whole into
a thick jelly, which may be sweetened, and flavored with ginger, cinnamon, brandy,
etc., if not contra-indicated — the dose of which is from two to four fluidounces three or
four times a day. The mucilage will also be found valuable in cough, diarrhea, and
dysentery, and as a tonic during convalescence from exhausting diseases.

PAPAVER SOMNIFERUM.

POPPY.

Opium is the concrete juice of the unripe capsules of the poppy plant, and is much
employed in the practice of medicine to fulfill various indications according to circum-
stances, as sedative, antispasmodic, diaphoretic, and febrifuge. In combination with
Ipecacuanha, as in the compound powder of Ipecacuanha and Opium, or in the com-
pound tincture of Virginia Snakeroot, it is employed as an anodyne and diaphoretic,
in all febrile, inflammatory, and painful affections, as well as in cases of nervous irri-
tability, morbid vigilance, restlessness, hysteria, spasmodic action, and increased
mucous secretions. It is frequently useful, in one of the above preparations, in false
pains, after-pains, and rheumatism of the uterus, or it may be. given alone for the same
purpose. Combined with Capsicum and Ipecacuanha, it forms a very valuable remedy
in cough and hemorrhages, especially uterine hemorrhage. It has been given alone,
to arrest too powerful action of the uterus during labor, but it does not always effect
the desired result. In dysmenorrhea it has sometimes afforded relief, when added to
Ergot and Camphor. Indeed, it may be advantageously used in all cases where an
anodyne-diaphoretic is indicated; where there exists an excessive mucous secretion;
where the functions of the uterus have been recently disturbed from exposure, as in
suspended or checked lochia, or suppressed menstruation; where severe pain is pres-
ent, and in spasmodic affections generally. It is contra-indicated where there is a
great amount of inflammatory excitement, until this is somewhat reduced; where there
exists a strong determination of blood to the head; where there is a deficient secretion
from inflamed mucous surfaces; generally, in constipation, and where it produces those
phenomena known as the idiosyncratic action of Opium.

Opium is employed internally in the form of powder, pill, or tincture: its dose, in
substance, is from one-fourth of a grain to three grains, according to its influence
upon the patient, and the indication to be fulfilled. The medium dose to procure sleep
and ease pain, is one grain; sometimes larger quantities are necessary, as in tetanus,
severe pain, etc. The dose of the tincture (Laudanum) is from ten to sixty drops.

MATERIA MEDICA.

731

When it can not be taken by mouth, it may be made to produce its influence on the
system by injecting it into the rectum, about twice the quantity required by mouth
being used, and added to a small quantity of water, starch-water, or elm mucilage.

Its various salts of Morphia possess similar properties, and are generally employed
as substitutes, the dose of either being from one-eighth of a grain to half a grain, in
powder, pill, or solution. Sulphate of Morphia is more commonly used in this country,
a solution of which may be made by dissolving eight grains of the Sulphate of Morphia
in eight or ten drops of Elixir of Vitriol, and about a fluidrachm of Alcohol, and then
adding half a pint distilled water. The dose of this solution, for an adult, is from
half a fluidrachm to two fluidrachms: one fluidrachm contains about one-eighth of a
grain of the sulphate.

An overdose of Opium, or any of its salts, may be treated by emetics of Mustard
and Lobelia-seed, with strong coffee, stomach-pump, external counter-irritation, cold
applications to the head and spine, forced exercise, galvanism and artificial respira-
tion. As soon as consciousness is once fairly restored, an active cathartic, with forced
exercise to a moderate extent, generally completes the cure.

PODOPHYLLUM PELTATUM.

MANDRAKE.

An indigenous, perennial plant, frequently known by the name of May-apple. The
dried root is emetic, cathartic, alterative, anthelmintic, emnicnagogue, hydragogue, and
sialagogue. It is frequently used with advantage in bilious, typhoid, and puerperal
fevers, as a cathartic or emeto-cathartic, frequently breaking up the disease at once;
and is likewise employed in hepatic affections, answering a purpose which renders it
superior to any mercurial preparation. It has been found very beneficial in dysmen-
orrhea, amenorrhea, and leucorrhea, in which it is usually administered with Black
Cohosh, Blue Cohosh, or other uterine tonic. The dose of the powdered root, as a
cathartic, is from ten to thirty grains; as a sialagogue and alterative, from three to
ten grains. Of the tincture, from ten to sixty drops act as a cathartic, and from five
to twenty drops, as an alterative and sialagogue.

PODOPHYLLUM, is the name given to the resinous principle obtained from the
Mandrake: it possesses the properties of the root in a superior degree, and is exten-
sively employed wherever an active cathartic is required, as well as to fulfill several
of the indications for which mercurials are recommended and used. Beside its
cathartic effect, it exerts an emmenagogue influence, which renders it frequently
serviceable in amenorrhea: in the following form it has been found especially service-
able in this affection:

Podopyllin, five grains,
Carbonate of Iron,

White Turpentine, of each, ten grains. Mix.
Divide the mass into ten pills, the dose of which is one pill three or four times a day.
In dysmenorrhea it may be frequently added to the medicines exhibited, with decided
benefit; thus, the following has proved useful in obstinate dysmenorrhea, attended with
a discharge of membranous shreds :

Jt. Podophyllin, five grains, {

Ergot, one scruple,

Camphor, two scruples. Mix.

732 AMERICAN ECLECTIC OBSTETRICS.

Divide into ten powders, of which one is a dose, and may be repeated twice a day.
It will be found more advantageous when given to females of full, plethoric habits.
Half a grain of Podophyllin, added to one or two grains of the inspissated juice of
Conium Maculatum, and made into a pill, will also be found useful in dysmenorrhea;
one pill may be given two or three times a day.

In leucorrhea, the following pill, in combination with vaginal injections of a decoc-
tion of Black Cohosh and Geranium-root or Tannic Acid, has effected prompt and per-
manent cures :

Cimicifugin, one scruple,
Leptandrin, ten grains,

Podophyllin, two and a half grains. Mix.

Divide into ten pills or powders, of which one is a dose, and which is to be repeated
two or three times a day. To form the above into a pill-mass, either simple Syrup, or
mucilage of Gum Arabic, in sufficient quantity, must be added.

As a cathartic, Podophyllin will in many instances prove valuable in puerperal fever,
phlegmasia dolens, puerperal phrenitis, and puerperal mania. Its tendency to produce
irritation and pain of the stomach or bowels, may be obviated by combining it with
Caulophyllin, Castile Soap, Ginger, Alkalies, or extract of Hyoscyamus, and it should
be remembered that the action of the resin is very much increased by thoroughly
triturating it with Loaf Sugar, Sugar of Milk, Ginger, Caulophyllin, or other soluble
substance.

In very small doses, and triturated with Leptandrin and Sugar of Milk, it will be
found a superior remedy in the various attacks of summer complaint to which children
are subject, especially in those cases attended with a determination of blood to the
head and accompanying torpor of the liver.

In cases of hepatic torpor, or when this is connected with other affections common
to females, in dysentery, and constipation, the following pill will be useful :

Jfc. Leptandrin, half a drachm,
Podophyllin, fifteen grains,
Extract of Rhubarb, one drachm. Mix.

Divide into thirty pills, the dose of which is from one to three pills, once or twice
a day.

The dose of Podophyllin is from one-eighth of a grain to one grain, repeated as the
case requires. It is frequently added to Cimicifugin, Caulophyllin, Senecin,' Aletridin,
etc., in female diseases attended with constipation, or derangement of the hepatic
functions; in cases of pregnancy, it should be administered with great caution. With
those persons in whom the smallest doses of Podophyllin produce nausea, or griping,
or other unpleasant symptoms, Iridin will be found an efficient substitute.

POLYGONUM PUNCTATUM.

WATER PEPPER.

A well known annual plant, also recognized by the name of Smart Weed. The whole
erb is medicinal, and possesses stimulant, diaphoretic and emmenagogue properties
he infusion, prepared in cold water, has been successfully used in amenorrhea,

MATERIA MEDICA.

733

dysmenorrhea, and in deficient lochial discharge ; it is likewise stated to form
valuable local application in the sore-mouth of nursing women. The dose of the in
sion is from two to four fluidounces, three or four times a day.

The tincture of Water Pepper, made by macerating the fresh herb in Holland gin
or proof spirit, has also been successfully exhibited in the above maladies, as well as
in moderate menorrhagia; it is said to cause a warmth and a peculiar tingling sensa-
tion throughout the system, with slight aching pains in the hips and loins, and a sense
of weight and tension within the pelvis. The dose is from one to four fluidrachms,
three times a day.

The extract of Water Pepper is a very neat form in which to exhibit the remedy, it
possesses all the properties of the plant, and may be substituted for its infusion or
tincture, in all cases. The following pill, in which it enters, has been successfully
administered in obstinate amenorrhea :

Podophyllin, eight grains,

Cimicifugin,

Dried Sulphate of Iron,

Extract of Water Pepper, of each, twenty-four grains,
Oil of Savin, twenty minims. Mix.

Divide the mass into twenty-four pills, the dose of which is one pill, three times
a day.

The dose of the extract of Smart Weed is from two to ten grains, three times a day.

POLYGONUM FAGOPYRUM, or common Buckwheat, may be used to recall the flow
of milk in the breasts of nurses, where it has disappeared for several days. Any
amount of buckwheat flour is to be stirred in a sufficient quantity of Buttermilk to
form a poultice, which is then to be merely warmed, and applied over the whole breast;
in five or six hours it may be renewed. Sometimes it requires to be thus used for three
or four days in succession, before its effects will be produced ; generally, however,
twenty-four hours will be sufficient.

POLYTRICHUM JUNIPERUM.

HAIR-CAP MOSS.

An indigenous perennial plant, which, employed in infusion, has a powerful diuretic
influence. It may be used in plethora, in all cases, where depletion by diuresis is
desired, in urinary obstructions, in febrile and inflammatory diseases, and in dropsical
affections. It possesses but little smell or taste, and never produces any nausea or
disagreeable sensation in the stomach. In doses of two fluidounces of the infusion,
repeated every half hour, it has been known to remove from a dropsical patient from
twenty to forty pounds of water in the space of twenty-four hours. However, cases
are occasionally met with, in which it fails to exert a diuretic influence. It is some-
times combined with Marshmallows, or other diuretic agents, where a demulcent effect

desired, but its diuretic properties are not increased by the combination.

734

AMERICAN ECLECTIC OBSTETRICS.

POTENTILLA CANADENSIS.

FIVE-FINGER.

A perennial plant, cofaimon to the United States, which possesses tonic and astringent
properties. A decoction of the plant has been found beneficial in febrile diseases,
diarrhea of children and puerperal females, night-sweats, excessive lochial discharge,
and in menorrhagia ; also as a local application in ulcerated mouth and throat, and for
spongy, bleeding gums. The dose of the decoction, is from two to four fluidounces,
three or four times a day.

PTERIS ATROPURPUREA.

ROCKBRAKE.

An indigenous perennial fern, possessing astringent and anthelmintic properties.

decoction, made by adding four drachms of the plant to a pint of boiling water, and
given in half fluidounce doses, repeated every two or three hours, has been used suc-
cessfully in diarrhea and dysentei-y ; it has also proved useful in night-sweats, menor-
rhagia, and excessive lochial discharge; also as a local application in ulcerations of
the mouth and fauces, and as a vaginal injection in leucorrhea. A strong decoction
has been successfully employed as a remedy for worms.

PTEROSPORA ANDROMEDA.

CRAWLEY.

A rare and singular perennial plant, indigenous, the root of which possesses prompt
and powerful diaphoretic virtues. It has been successfully exhibited in febrile and
inflammatory diseases. Combined with Caulophyllin, it forms an excellent agent in
amenorrhea and dysmenorrhea; and is unsurpassed in after-pains, suppression of
lochia, and the febrile symptoms which sometimes occur at the parturient period.

A very valuable diaphoretic may be made as follows:

Tjc. Crawley,

Pleurisy-root, of each, ten grains,
Bloodroot, three grains,
Ipecacuanha, one grain. Mix.

Divide into two powders, one of which may be administered every hour or two. In
some cases, the addition of nitrate of Potassa, three or four grains to each dose, will
render the powder more promptly efficacious.

The scarcity and high price of Crawley, has prevented it from coming into general
use. Its dose is from twenty to thirty grains of the powdered root, given in water,
tea, cider, or lemonade (as may be allowed), as warm as the patient can drink, and
repeated every hour or two according to circumstances. The compound powder of
Ipecacuanha and Opium, when prepared with nitrate of Potassa instead of the bitar-
trate, forms a substitute for Crawley, much superior to it in its general effects.

MATERIA MEDICA.
PYRETHRUM PARTHENIUM.

735

FEVERFEW.

A common perennial plant, possessing emmenagogue, carminative, and vermifuge
properties. The warm infusion is an excellent remedy in recent cold, worms, flatu-
lency, suppressed menstruation, suppression of lochial discharge, and in hysteria. A
teaspoonful of the compound spirits of Lavender forms a valuable addition to the dose
of the infusion, in hysteria and flatulency. The dose of the infusion is from two to
four fluidounces, every one, two, or three hours. The leaves applied as a fomentation,
are useful in severe pain or swelling of the bowels.

RUBIA TINCTORIUM.

MADDER.

A native of the south of Europe, the root of which is supposed to possess emmena-
gogue and diuretic properties. Thirty grains of the powdered root, repeated three or
four times a day, is the dose ; this has been exhibited in amenorrhea, by some practi-
titioners, combined with one or two grains of Cimicifugin, and with reputed success.
However, it is not in general use, as the profession lack confidence in its action.

RUBUS STRIGOSUS.

RED RASPBERRY.

RUBUS TRIVIALIS.

DEWBERRY.

RUBUS VILLOSUS.

BLACKBERRY.

These are well known plants, which possess considerable medicinal virtues. The
leaves of the Red Raspberry, in infusion or decoction, are strongly astringent, and
have been found an excellent remedy in diarrhea, cholera-infantum, relaxed condi-
tions of the intestines of children, and passive menorrhagia ; they are also said to
exert an influence over the uterus during parturition, exciting its contractions when
other agents have failed, and have been found serviceable in after-pains. As a local
application, the decoction has been found beneficial in leucorrhea and prolapsus uteri.
The dose of the decoction is from one to four fluidounces, several times a day; it is
frequently combined with equal parts of Black Cohosh and Blackberry roots. The
syrup of Raspberry, in water, forms a refreshing and beneficial beverage for fever
patients, and during convalescence.

Dewberry, and Blackberry roots, are used principally on account of their astrin-
gency. They may be given in decoction, in the same doses as that, of Raspberry, or
from twenty to thirty grains of the powdered bark of the root. They will be found
very efficacious in diarrnea, passive menorrhagia, excessive lochial discharge, and in
the summer complaints of children. Blackberry-jam is well adapted to cases of
diarrhea, dysentery, and cholera-infantum ; also in diarrhea during typhoid and other
fevers.

736

AMERICAN ECLECTIC OBSTETRICS.

RUTA GRAVEOLENS.

RUE.

A well known perennial plant, the leaves of which possess emmenagogue, anthel-
mintic, and antispasmodic properties. The warm decoction or infusion is a popular
remedy in recent amenorrhea, and in suppression of the lochial discharge. It excites
a special action upon the uterus, and when improperly administered is capable of
exciting menorrhagia, inflammation of the intestines and uterus, and, in pregnant
females, miscarriage. The oil of Rue, has been taken with the criminal intention of
producing abortion, and has been almost invariably followed by dangerous symptoms,
as gastro-intestinal inflammation, and cerebral derangement, sometimes terminating
fatally.

It has however, been used successfully in hysteria, flatulent colic, nervous excita-
bility, and in worms; but should never be given to pregnant females, or those subject
to large floodings, or menorrhagia. The dose of the powdered leaves is from ten to
twenty grains; of the decoction, from one to four fluidounces.

SANGUINARIA CANADENSIS.

BLOODItOOT.

An indigenous, perennial plant, possessing expectorant, alterative, and emmenagogue
properties. It is seldom employed in obstetrical practice, though it has been found
useful in amenorrhea, and in female difficulties connected with hepatic torpor. In
these latter instances, it may be advantageously added to Caulophyllin, Senecin, Cim-
icifugin, or whatever uterine remedy may be prescribed.

Bloodroot formed into a tincture with elixir of Vitriol, or diluted Sulphuric Acid, is
an excellent remedy for many cutaneous diseases, as ringworm of the scalp, scaldhead,
tetter, ringworm, etc.

Ten to twenty grains of the powdered root, or from twenty to sixty drops of the
tincture, will act as an emetic; from three to five grains of the powdered root, may be
used as a stimulant, expectorant, or emmenagogue: and from half a grain to two
grains, as an alterative. Sanguinarin, a principle obtained from the root, and supposed
to contain its alkaloid and resinoid principles, has been found very efficacious in
amenorrhea, dysmenorrhea, and other functional disorders of the female generative
system, in combination with equal parts of Caulophyllin, and the alcoholic extract of
Cimicifuga.

SARRACENIA PURPUREA.

SAEEACENIA.

An indigenous, perennial plant, commonly known as the Sidesaddle flower. Its vir-
tues are not fully ascertained. Equal parts of Sarracenia, Blue Cohosh, and Buck-
horn brake, in the form of syrup, have been found very useful in chlorosis, amenor-
rhea, and other uterine derangements, in the dose of one or two fluidounces, three or
four times a day. An infusion of the leaf, or root, is also efficacious in amenorrhea,
dysmenorrhea, and other functional derangements of the uterus, connected with a
sluggish or torpid condition of the organ. The dose of the powdered root, is from
twenty to thirty grains, three or four times a day ; of the infusion, from one to three
fluidounces.

MATERIA MEDICA.

737

SCUTELLARIA LATERIFLORA.

SCULLCAP.

An indigenous, perennial herb, possessing tonic, nervine, and antispasmodic proper-
ties. It has been found especially beneficial in chorea, convulsions, and nervous affec-
tions generally, attended with excitability, restlessness, or •wakefulness. In the cases
of children whose healths are impaired by teething, it has been given with advantage.
As there is no danger in using the article, the powder or infusion may be taken freely.
It is sometimes combined with Blue Cohosh or Black Cohosh, in cases of nervous head-
ache, nervous irritability, or mental excitement of females, and especially when these
conditions exist during pregnancy or at the time of labor.

SCUTELLARINE, is the concentrated preparation obtained from Scullcap. It may
be prepared as follows : A tincture of the herb is made with diluted Alcohol, and then
the alcohol is distilled off until the residue is of the consistency of molasses, when this
is mixed with several times its weight of Water, and then precipitated with Alum, or
some other soluble salt. The precipitate is freed from the salt used in precipitation, by
one or two washings in water, and dried; and while it is not chemically pure, it is
sufficiently so as to be of great use in medicine. The green color of the powder is
owing to the chlorophylle, or coloring-matter, not having been separated from the pre-
cipitate; and if the chlorophylle be possessed of no medical virtue, it acts simply as
an adulterant in the compound.

As far as this has been tested chemically, it has manifested neither acid nor alka-
line reaction, and as it is not a resin, it is classed among the neutral principles with
salicine.

This is one of our most valuable nervines and tonics, and is especially useful in
cases of depression of the nervous and vital powers after sickness, over-exercise,
excessive study, or from long-continued and exhausting labors. One grain will
frequently produce its quiet and soothing effect, controlling nervous agitation, and
inducing a sensation of calmness, and strength.

Scutellarine has been advantageously combined with Cypripedin, Cimicifugin, and
Caulophyllin, in various female difficulties, both in the pregnant and non-pregnant
condition, accompanied with an excitable or irritable conditon of the nervous system.
Its dose is from one to five grains three or four times a day, though an increased quan-
tity will not be productive of any unpleasant effects.

SECALE CORNUTUM.

ERGOT.

Ergot is diseased rye, upon the grains of which a fungus growth occurs, and which
is named Ergotetia Abortifaciens. Ergot is used in medicine principally on account
of its power of promoting uterine contractions in languid natural labors. The con-
tractions caused by it are very unlike those observed in the natural parturient process,
being strong and continuous, and of a spasmodic character, without any periods of
relaxation; in consequence of this continued pressure exerted upon the child, and
especially when the parts are not sufficiently soft and yielding, it is generally more or
less injured, and frequently destroyed. As sufficient reference has been made to its

738

AMERICAN ECLECTIC OBSTETRICS.

use in labor on pages 347, 348, I will omit any further observations relative thereto at
this place. (See note on page 708.)

It is sometimes administered to facilitate abortion, when it has once commenced
and can not be checked. (Seepages 188, 189.)

In uterine hemorrhage, both during the gravid and non-gravid state, Ergot has fre-
quently been administered to check it, and it has likewise been advised in retained
placenta, mole, hydatids, a clot of blood, etc., to expel these when the organ has once
commenced acting. In paiiful dysmenorrhea, accompanied with membranous shreds,
it has frequently proved beneficial when given in combination with Camphor.

It is sometimes prescribed in amenorrhea, but this is improper, because if given in
sufficient doses to produce a discharge, permanent injury may be inflicted upon the
female.

The ethereal oil of Ergot may be prepared by forming an ethereal tincture, and
evaporating the other. It possesses the properties of Ergot, while the oil by expression
does not. As a parturient, it may be given in doses of from twenty to fifty drops, in
water, tea, or some other aromatized syrup.

The dose of powdered Ergot, in the ordinary affections for which it is recommended,
is from five to fifteen grains three times a day ; but its use should not be continued for
any great length of time, on account of its tendency to cause dangerous symptoms.
As a parturient, it is generally given in doses varying from one to two drachms: my
usual mode of exhibiting it, in order to arouse uterine contractions, is to place a
drachm or two in about four fluiJounces of hot water, and give a tablespoonful every
ten minutes, until the pains are induced or become active, and which generally occurs
in from twenty to thirty minutes, and frequently much sooner.

The tincture of Ergot may be used as a substitute for the article, in substance, in all
cases where this is indicated or desired; the dose is one or two fluidrachms. A fluid
extract has been prepared from Ergot which possesses the virtues of the article is
pleasant to the taste, and acts promptly without nausea. Its dose is from half a flui-
drachm to a fluidrachm, being equal to one or two full parturient doses of the powder.

SENECIO GRACILIS.

FEMALE REGULATOR,

This is an indigenous, perennial plant, the root and herb of which, together with
those of Senecio Aureus, Life-root, exert an especial influence upon the female repro-
ductive organs. In amenorrhea, not connected with some structural lesion, it has
proved very efficacious, used alone in infusion, or combined with equal parts of Savin
and Canada Snakeroot. In dysmenorrhea, it has also proved valuable, in which diffi-
culty it is frequently combined with Aletris Farinosa. An infusion of Cinnamon,
Raspberry leaves, and Senecio, has been found very serviceable in menorrhagia, to be
administered both at the time of the discharge, and during the intervals. The dose of
the decoction or infusion, is from two to four fluidounces, three or four times a day. A
fluid extract, prepared from the plant, forms a very useful agent in amenorrhea, and
other uterine diseases, in doses of from half a fluidrachm to a fluidrachm, three or
four times a day; it may also be advantageously used in combination with the fluid
extract of Water Pepper, Black Cohosh, etc.

SENECIN, is the concentrated preparation obtained from Senecio Gracilis. It pos-

\

MATERIA MEDICA. 739
\

sesses the virtues of the plant in a high degree, and may be employed in all the uter-
ine derangements in which the plant is used.

A very valuable pill, in uterine difficulties, is made as follows :

^c. Caulophyllin, two scruples,

Senecin,

Extract of Water Pepper, of each, one scruple. Mix.
Divide the mass into twenty-five pills, the dose of which is one, to be repeated three
times a day.

In chlorosis, with amenorrhea, the following pill has been used, and with much effi-
cacy :

Dried sulphate of Iron, two scruples,
Senecin,

Aletridin, of each, one scruple. Mix.

Divide the mass into twenty-five pills, the dose of which is one, to be repeated three
times a day.

In menorrhagia, Senecin has been advantageously combined with Geraniin ; or its
ethereal tincture may be administered, with benefit, in some astringent infusion.
Equal parts of Senecin, inner bark of Cotton root, and Cinnamon bark, made into a
tincture, have likewise been successfully exhibited in this affection.

In dysmenorrhea, benefit has been derived from the use of the following pill :

Jfc. Camphor, two and a half drachms,

Sulphate of Quinia,

Extract of Belladonna, of each, one scruple,
Senecin, a quantity sufficient to form a pill-mass.

Mix, adding a few drops of Alcohol, if the Senecin be too hard, and divide the mass
into eighty pills. The dose is two pills every hour during the menstrual period, until
the pain ceases, and one pill, three or four times a day, in the intervals.

The dose of Senecin, is from one to three, or five grains, three times a day.

SOD^E BORAS.

BORATE OF SODA.

Commonly known as Borax. Its medicinal actions are not perfectly understood. It
undoubtedly exerts an influence upon the uterus, and has been successfully adminis-
tered in amenorrhea, dysmenorrhea, to facilitate parturition, or to aid in the expulsion
of the placenta. In such instances it has been used alone, or combined with other agents,
as Cinnamon, Ergot, Blue Cohosh, etc. In doses of ten grains, repeated three or four
times a day, it has produced abortion, attended with pains all over the system, and
excessive debility of the joints, which remained for several months, in a greater or lesa
degree; on this account, its administration to pregnant females is improper. The dose
of Borax, as an emmenagogue, is from ten to thirty grains, dissolved in water, or in
Infusion of Elm or Flaxseed.

A solution of Borax is frequently employed as a beneficial local application to
nflamed and sore nipples, pruritus vulva, and aphthous ulcerations of the mouth and
fauces. ( See author's Am. Disp. — Solution of Borax with Morphia.)

740

AMERICAN ECLECTIC OBSTETRICS.

SPIRIT VAFOR BATH.

A Spirit Vapor-Bath, or hot air bath, exerts a most powerful, yet beneficial influ-
ence upon the whole system, aiding very materially our endeavors to remove disease.
This highly valuable mode of producing activity of the cutaneous vessels, has long
been practiced in many sections of the country as a domestic remedial agent, and was
first introduced to the notice of the medical profession by myself, about twenty-nine
years ago, since which it is in much use among physicians. The advantages to be
derived from this method of producing perspiration are very great, and it is not fol-
lowed with any of those injurious consequences which often attend the internal admin-
istration of a sudorific.

It is to be given as follows: The patient is undressed, ready for getting into bed,
having removed the shirt and underclothing worn through the day, and puts on a
night-shirt or other clothing to be worn only while sweating, and during the night, if
the bath is taken at bedtime. He is then seated on a high Windsor, or wooden-bot-
tomed chair, or instead thereof, a bench or board may be placed on a common open
bottomed chair, care being taken that the bottom is so covered that the flame will not
burn him; after seating himself, a large blanket or coverlid is thrown around him
from behind, covering the back part of his head and body, as well as the chair, and
anothera-must be passed around him in front, which last is to be pinned at the neck,
loosely, so that he can raise it and cover his face, or remove it down from his face from
time to time, as occasion requires, during the operation of the bath. The blankets
must reach down to the floor, and cover each other at the sides, so as to retain the
vapor and prevent it from passing off.

This having been done, a saucer, or tin vessel, into which is put one or two table-
spoonfuls of whisky, brandy, spirits, alcohol, or any liquor that will burn, is then
placed upon the floor, directly under the center of the bottom of the chair, raising a
part of the blanket from' behind to place it there; then light a piece of paper, apply
the flame to the liquor, and as soon as it kindles let down the part of the blanket
which has been raised, and allow the liquor to burn till it is consumed, watching it
from time to time to see that the blankets are not burned; as soon as consumed, put
more liquor into the saucer, about, as much as before, and again set it on fire; being
very careful to pour no liquor into the saucer while the flame exists, as there would be
danger of burning the blankets, patient, and perhaps the house.

Continue this until the patient sweats or perspires freely, which in a majority of
cases will be in five or ten minutes.

If during the operation the patient feels faint or thirsty, cold water must be sprinkled
or dashed in his face, or he may drink one or two swallows of it — and in some cases,
the head may be bathed with cold water.

As soon as free perspiration is produced, wrap the blankets around him, place him
in bed, and cover him up warm, giving him about a pint of either good tea, ginger, or
some herb tea to drink, as warm as he can take it. After two or three hours, remove
the covering, piece by piece, at intervals of twenty or twenty-five minutes between
each, that he may gradually cease perspiring.

There is no danger of taking cold after this Spirit Vapor Bath, if the patient uses
ordinary precaution; and if his disease will allow, he can attend to his business on
the next day the same as usual. In fact, the whole is a very safe, agreeable, and bene-
ficial operation, much more so than a mere reading of the above explanation would lead
one to suppose.

This bath, which is more properly a hot-air bath, is very useful in colds, and all
febrile and inflammatory attacks, whenever it can be employed by the patient. It

MATERIA MEDIC A.

741

will be found very valuable in recent amenorrhea, and dysmenorrhea, and sometimes
in suspended lochia, and some of the febrile or inflammatory attacks during the puer-
peral period ; it has likewise been recommended in cases of rigid os uteri. In these
latter instances, it should be used with prudence.

STATICE CAROLINIANA.

MARSH ROSEMARY.

An indigenous, perennial, maritime plant, the root of which is powerfully astringent,
and has been employed in infusion or decoction, in diarrhea and dysentery. The
decoction is principally employed, however, as a local application in leucorrhea, pro-
lapsus uteri, prolapsus ani, and aphthous ulcerations of the mouth and throat. The
dose of the decoction is one or two fluidounces, every one, two, three or four hours

TANACETUM VULGARE.

TANSY.

A well known plant, possessing tonic, diaphoretic, and emmenagogue properties. The
cold infusion is tonic, and is frequently used in jaundice, dyspepsia, flatulency, and
worms. The warm infusion is useful in recent amenorrhea, tardy labor-pains, and
suspended or deficient lochia. Used as a fomentation to the bowels, the herb has been
useful in inflammatory conditions of the abdominal viscera, in amenorrhea, and in
painful dysmenorrhea.

Oil of Tansy has been used with efficacy as a vermifuge, but is seldom administered
on account of its bitterness. It has also been employed criminally to produce abor-
tion, but almost always with fatal results.

The dose of Tansy, dried and powdered, is from thirty to sixty grains, two or three
times a day; of the infusion, from one to four fluidounces; of the oil, as a vermifuge,
from two to five drops.

TRILLIUM PENDULUM.

BETH-ROOT.

T An indigenous, perennial plant, the root of which possesses tonic and astringent
properties. It has been used with benefit in monorrhagia, uterine hemorrhage, leucor-
rhea, and bleeding-piles; also in diarrhea and dysentery. It may be given in doses
of one drachm of the powdered root, or from two to four fluidounces of the strong
infusion. Equal parts of Trillium, Geranium, and Cimicifuga, have been used inter-
nally, in infusion, and as a local application in obstinate leucorrhea, and with efficacy,

VALERIANA OFFICINALIS.

VALERIAN.

A European plant, the root of which is extensively used as a tonic, and antispas-
modic. It is of service in all cases of irregular nervous action, as in the morbid

742

AMERICAN ECLECTIC OLSTETRICS.

wakefulness of fevers, in the irritability and restlessness occurring in hysterical con-
stitutions, in chorea, hysteria, etc.

When used in powder, the dose is from half a drachm to a drachm, three or four
times a day; in infusion, which is' less liable to irritate the alimentary canal, from one
to two fluidounces. It may be frequently combined, in infusion, with Scullcap, Skunk-
Cabbage, and Pleurisy-root, with advantage; and, in chorea, with Black Cohosh.

The fluid extract, which holds the virtues of the root in a concentrated form, may be
given two or three times a day, in doses of one or two fluidrachms. It may likewise
be advantageously added to other fluid extracts, as of Black Cohosh, Senecio, Pleurisy-
root, Ladies-slipper-root, etc. I have advantageously employed the alcoholic extract,
alone, and in union with Scutellarin, Caulophyllin, etc., in female diseases, attended
with nervous excitability.

The oil of Valerian is frequently substituted for the above forms of preparation, in
doses of four or five drops. The following forms an efficacious preparation for nervous,
hysterical, and sleepless cases:

tfc. Tincture of Lupulin,

Tincture of Hyoscyamus, of each, two fluidounces,

Camphor, one drachm,

Oil of Valerian, eleven minims. Mix.

The dose is one or two fluidrachms, two or three times a day. Another preparation,
of a somewhat like character, has been employed for a similar purpose:

Jji. Ethereal oil of Lupulin, one fluidrachm,
Oil of Valerian, half a fluidrachm,
Camphor, one drachm.

Mix together, and dissolve the Camphor in the oils; the dose is from five to ten drops,
on sugar, or in mucilage, two or three times a day.

VERATRUM VIRIDE.

AMERICAN HELLEBORE. -

An indigenous, perennial plant, the root of which possesses sedative properties when
given in small doses. A saturated tincture of the recent root has been employed to
produce diaphoresis, and to reduce the force and frequency of the pulse, which it has
sometimes brought as low as thirty-five beats in a minute. It has been successfully
employed in neuralgic and rheumatic affections, in typhoid fever, puerperal fever, mor-
bid irritability, chorea, spasmodic affections, and other instances where a sedative
influence has been desirable. It has been used with excellent results in some of the
febrile and inflammatory affections to which the puerperal female is subject. In large
doses it is emetic, and produces, when too long continued, or in improper quantities,
faintness, vertigo, somnolency, headache, dimness of vision, and dilated pupils.

The dose to an adult, is eight drops, in sweetened water, repeated every three hours,
increasing each dose one or two drops, until nausea, vomiting, or a reduction of the
pulse to sixty-five or seventy ensues; then reduce the dose one half. Any unpleasant
effects arising from its administration may be speedily relieved by Brandy, tincture of
Ginger, or Laudanum. (See author's Am. Disp. — Veratrum Viride.)

MATERIA MEDICA.

743

VERNONIA FASCICULATA.

IRON-WEED.

An indigenous, perennial plant, common to the Western States. The root, in powder
or decoction, has been found beneficial in amenorrhea, dysmenorrhea, leucorrhea, and
menorrhagia. It appears to exert a tonic influence upon the uterus. The dose of the
powdered root, is from twenty to thirty grains, three or four times a day; of the
decoction, one or two fluidounces; of a saturated tincture, from half a fluidrachm to
two fluidrachms.

VIBURNUM OPULUS.

HIGH CRANBERRY.

An indigenous shrub, common to the Northern States, the bark of which is a power-
ful antispasmodic, and hence is more generally known as Cramp-bark. It is very use-
ful in relieving spasms and cramps of all kinds, especially those to which pregnant
females are subject. A decoction or wine of the bark, used during pregnancy, will, it
is said, prevent any attacks of cramp, hysteria, etc., and also render the female less
disposed to puerperal convulsions, or irregular uterine contractions, during labor.
These preparations may be used in doses of two fluidounces, two or three times a day.

The alcoholic extract will be found a very valuable preparation, and may be used in
all cases in which the bark is indicated. In uterine difficulties, it may be beneficially
combined with Caulophyllin, Cimicifugin, Aletridin, Senecio, Asclepidin, etc. In bil-
ious and flatulent colic, spasmodic pains of the stomach and bowels, its combination
with Dioscorein, will be found advantageous. The dose of the extract, is from one to
five grains, three times a day.

744 AMERICAN ECLECTIC OBSTETICS.

TABLE

For determining the Time at which Menstruation, Quickening, Parturition, etc.,
may be expected to take place.

This table is so arranged that the dates on the same line in the several columns are
consecutively 28 days or one lunar month distant from each other. Thus, if a female
menstruates on the 7th January, her next period will occur 28 days subsequently, on
the 4th February, the next on the 4th March, then 1st April, and so on.

Pregnancy is usually dated from the last menstruation, on account of the difficulty
of determining the precise period of a fruitful coitus; 280 days after the last menstru-
ation is the usual period allowed for full term of pregnancy; or, 275 days from a
fruitful coitus, when this is known. Hence 5 days may be allowed in the calculation
with the accompanying table; thus, if a pregnant female had her last menstruation on
29th July of any year, her period of confinement will occur at about 280 days or ten
lunar months subsequently, which, upon counting, we find will be on the 8th of April
of the ensuing year; or by allowing five days, we may expect her labor to come on
between the 8th and 13th of April.

Quickening is generally supposed to be first experienced at about the 140th day of
pregnancy; hence, if a female perceives quickening for the first time on 11th August,
by counting along in the table for the balance of the period of pregnancy, that is,
140 days or five lunar months, we find that labor will probably occur upon or about
the ensuing 29th December. I say, probably, because there is less certainty in this, as
quickening may be perceived at a much earlier period, or, at a more advanced stage of
the pregnancy.

After December, the present year in question terminates, so that, upon finding on
what day in January, in the last or 14th column, the counting along on the same
line terminates, and it is necessary to count on still farther, we must return to the
same date of January in the first column, as we left in the last or 14th column, and
then count along on the corresponding line as far as may be required. Thus, if we
desire to count 9 lunar months from 18th October, we find that 3 lunar months brings
us to 10th January of the next year in the last or 14th column — we now find the 10th
January in the first column, and by counting along for the balance of the time, 6 lunar
months, it brings us to the 27th June of the subsequent year.

In leap year one day may be deducted from the ascertained period, after having
passed the month of February of the leap year; thus, 280 days from 19th November
would be 20th August of the ensuing year — but, if this be a leap year, it will be 25th
August; again, 280 days from 13th August would be 20th May of the next year, or, if
leap year, 19th May.

By reference to the figures at the bottom of each column, counting from the first
column, we can always determine how many lunar months or columns must be included
within any number of days, and vice versa. Thus, 6 lunar months or columns are
equal to 168 days — then 168 days from the 18th July would be 6 columns or lunar
months, carrying us to 2nd January of the next year. The reader may find various
other uses for this table.

J. KING, M. D.

MATERIA MEDICA.

745

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IInTDEZ.

Abdomen, enlargement of, - Page 107

laxity of, 1G9

rigidity of, - 169

subsidence of, - 244

Abdominal palpation, - 113

Abdominal pregnancy, - - 138, 141
Abnormally large pelvis, - - 33, 367

Abortion, - 177

causes of, 178

diagnosis of, - - - - 181

hemorrhage during, - 185, 189

prognosis of, - - - - 182

symptoms of, - - - - 180

treatment of, - - - - 184

Abscess, mammary, - - - 653

Accidental hemorrhage, - - 478

diagnosis of, - - - - 479

treatment of, - - - - 480
Accoucheur, conduct of, during the

first stage of labor, - - 260
conduct of, during the second

stage of labor, - 270
conduct of, during the third

stage of labor, - 277

Acute Tympanites, - 650

Adherent placenta, - - 499, 506
Adherent placenta in hour-glass

contraction, - 602
Affections of the bladder during

pregnancy, - 159

After-pains, ----- 290

After-treatment of hemorrhage, - 493

Agglutination of the os uteri, - 359

Alimentation of the child, - - 298

artificial, - - - - 298

Allan tois, - 205, 220

Alvine evacuations of the child, 286, 297

Amnion, ----- 201

Amniotic fluid,
Amnii liquor,
excess of,
Anaesthesia, -

Page 201
201

328
428, 542

Anorexia during pregnancy, - 149

Anterior commissure of the vulva, 57

Anterior lip of os uteri, retention of, 341

Anteversion of the uterus, - - 173

Antidotes to gelseminum, - - 336

Anus, prolapsus of, - - - 167
Aorta, compression of, by Prof. C. D.

Meigs, ... 490

Aphtha;, 675

symptoms of, - - - - 675

treatment of, - - - - 676

Apoplexy, ----- 527

fetal, 279

Application of the bandage, - - 282

blunt hook, - 553

forceps, ----- 569

perforator, - 593

Arch of pubes, - - - - 16

Areola, in pregnancy, - - - 106

Arm, presentation of, - - 304, 419

Articulations and ligaments of pelvis, 17

Ascites of the fetus, - 354

Asphyxia, fetal, - 278

Attention to the bowels, 257, 265, 292

to the urine, 258, 265, 267, 291, 326
required during the puerperal

state, 287

required subsequent to labor, 287, 299

Attentions to the child, - 280, 297

Attitude of the fetus, - - - 227

Audible signs of pregnancy, - 109

Auscultation in pregnancy, - - 109

Axis of the inferior strait, - - 26

of the pelvis, - 26

AMERICAN ECLECTIC OBSTETRICS.

748

Axis of the superior strait,

24

Bag of waters,

251

to distinguish from fetal scalp, 254, 2G3

Ballottement,

114

Bandage, application of,

282

Bark of cotton-root,

329,

489,

612

Bastinadoing,

543

Baudelocque's pelvimeter,

42

Beating of fetal heart, -

110

Bed, putting to,

284

Bladder, affections of, -

159

calculus in,

355

descent of,

354

rupture of, - -

523

treatment of ruptured,

524

199

Blood, effects of loss of,

333,

428,

496

Blunt hook, -

553

Body of the uterus, changes

in dur-

ing pregnancy, -

120

Bones of the fetal head,

48

of the pelvis, -

9

Bowels, attention to,

257,

265,

292

Breasts, enlargement of,

106

inflammation of,

653

Breathing, difficult during pregnancy,

161

Breech, how to distinguish,

408

Breech-labors, management of difficult, 417

Breech-presentation,

305,

405

management of,

413

positions of, -

306,

409

Brim of the pelvis,

23

Broad ligaments, -

75

Brow presentation,

387

Bruit de souffle, -

109

Caducous membrane,

195

Calcaneo-iliac positions,

308

Calcaneo-pubal position,

306

Calcaneo-sacral position,

306

Calcined deer's horn, in hemorrhage, 489
Calculus in the bladder during labor, 355
during pregnancy, - - - 176
Cancer of the os uteri, - 359
Caput succedaneum, - 254, 310, 323
Cardialgia during pregnancy, - 151
Carunculce myrtiformes, - 61
Carus, curve of, - 26
Cases in which the Cesarean opera-
tion may be performed, - 597

Cases for turning, -

546

Cases requiring craniotomy,

591

Cases requiring forceps,

564

Catarrh, nasal, - -

681

Catheter, 60, 131, 172, 267, 291,

326,

354,

570

Cauliflower tumor,

359

Cause of labor, -

243

Causes of abortion,

178

of phlegmasia dolens,

634

of puerperal fever,

615

of puerperal mania,

645

relaxation and separation of the

symphyses,

20

Cautions respecting the use of ergot,

348

Cavities of the pelvis, -

10, 22,

25

Cavity of the decidua, -

195

Cazeaux on diagnosis of placenta

prsevia, - - -

460

CephalEematoma, - - -

323

Cephalalgia during pregnancy,

154

Cephalic version, -

433,

545

Prof. Wright's,

433

Cephalo-iliac positions,

305

diagnosis of, -

420

Cervix uteri, -

63

changes in the,

117

fibrous tumors of the, -

362

Cesarean operation,

597

cases in which it may be used,

597

dangers of, -

597

mode of performing,

598

when to be performed, -

598

Cesarean section, -

697

Changes in the body of the uterus

during pregnancy,

120

Changes in the cervix uteri during

pregnancy,

117

Changes in the properties of

the

uterus during pregnancy, -

127

Changes in the uterus during preg-

nancy, -

117

Character of labor, determined,

264

Child, apoplexy of,

279

ascites of,

354

asphyxia of, -

278

attentions to the, -

280,.

297

delivery of the,

254,

274

diseases of, (see In/ants.)

food for the, -

298

holding the, -

280

INDEX.

749

528,

455,
101, 134,

Child, washing the, 284
Child-bed fever, .... 614
Children, plurality of, - - - 445
still-born, .... 278
Child's head, delay of in the pelvic

cavity, - * -
Chin from the breast, departure of,
Chloroform, - - 428, 476, 505,
Chorion, - - - - -
Cicatrix in the vagina, -
Circulation, fetal, - - - -
Classification of labor, -
Clitoris, - - - - -
Coccyx, -

Cold douche, - - - -
Colic of infants, -
Collection of feces in the rectum,
Colostrum, - - -

Commissures of the vulva, -
Complicated labor,
Compound pregnancy, -

presentations, - - -
Compression of the aorta.
Concealed hemorrhage, - - -

diagnosis of,

treatment, of - - -
Conception, - - - - -
Condition of the female in the first
stage of labor, - - -
in the second stage of labor, -
Condition of the os uteri, in the first
stage of labor, - - -
in the second stage of labor, -
Condition of the uterus in the first
stage of labor,
in the second stage of labor, -
Conduct of accoucheur during the
first stage of labor,
during the second stage of labor,
during the third stage of labor,
Constipation during pregnancy, -

of infants, -
Contraction, hour-glass,

irregular,
Contractions, fibrillar, -
painless uterine, -
uterine, -
Convulsions, apoplectic,
during pregnancy, -
epileptic,
hysterical,

357
387
542
200
357
229
248
58
13
539
669
356
286
57
469
445
403
490
478
479
480
93

249
252

251
252

251
252

Convulsions, puerperal,
Cord, around the neck, -
cutting umbilical, -
hemorrhage from, -
umbilical, -
umbilical around the neck,
umbilical, dressing the, -
prolapsus of the, -
umbilical, rupture of the,
umbilical, shortness of the,
umbilical, tying of,
Corpus Luteum, -

by Prof. C. D. Meigs, -
Coryza, -
Cotton-root, inner bark of,
Cough during pregnancy, -
Coutouly's pelvimeter, -
Cramp of the stomach during preg-
nancy, -
Cramps during pregnancy, -
Cramps during labor, treatment

of,

Craniotomy, - - - - -
cases requiring, -
dangers of, -
mode of operating, -
Cross-birth, -
Crotchet, -
Crural phlebitis, -
Crusta lactea, -
Curve of carus, -
Cutting the umbilical cord, -
Cyanosis, -

symptoms of, -
treatment of, -
Cystocele, vaginal, -

526
274
278
671
211
275, 351
285

326,

242,

155,

200
270
277
153
670
503
502
245
245
289
527
155
529
527

441

508
351
277
82
86
681

329, 489, 612
161
44

152
167

271

589
591
593
593
419
592
634
679
26
278
666
667
667
354

Dangers of Cesarean operation,

of turning, -
Davis' forceps, -
Death of the fetus,
Decapitation, -
Decidua, cavity of the, -

vera, -

reflexa, - - - -

serotina, -
Deciduous membrane, -
Deficient contractions, -

lochial discharge, -
Deformities of the pelvis, 29,

management of in labor,

597
549
557
238
433
195
196
196

196, 209
195
326
294

176, 367
367

750 AMERICAN

Delay of child's head in pelvic cav-
ity, ----- 357
Delivery in natural labor, position

for, 271

Delivery of the child, - - 254, 274

of the placenta, - - 255, 280

Departure of the chin from the breast, 387

Descent of the head, 310

of the os uteri, - 341

Despondency during pregnancy, - 102

Detachment of placenta, 484, 499, 504

Determining the character of labor, 264

Development of the fetus, - - 213

of the human ovum, - - 195

Diagnosis of abortion, - 181

of accidental hemorrhage, - 479

of breech presentation, - - 408

of concealed hemorrhage, - 479

of ear presentation, - - 400

of face presentation, - - 393

of feet presentation, - - 419

of hour-glass contraction, - 503
of inflammation of the uterine

appendages, - 626

of intestinal irritation, - 619, 651

of inverted uterus, - - 514

of knee presentation, - - 419

of left occipitoanterior position, 309

of left occipito-posterior position, 316

of occipito pubal position, - 315

of occipito-sacral position, - 321

of pelvic presentations, - - 408

of phlegmasia dolens, - - 639

of placenta prasvia, - - 458

of prolapse of the cord, - - 442

of puerperal convulsions, 527, 534

of puerperal mania, - - 646

of puerperal peritonitis, - 619

of right occipitoanterior position, 314
of right occipito-posterior position, 320

of rupture of the uterus, - 521

of shoulder presentations, - 420

of transverse presentations, - 440

of twins, - - - 135, 446

of uterine phlebitis, - - 624

of vertex presentations, - - 307

Diameters of the fetal head, - 51

of the inferior strait, - 24

of the pelvic cavity, - 26

of the superior strait, 23

Diarrhea after delivery, - - 6C2

OBSTETRICS.

Diarrhea, during pregnancy, - 150
Diet after labor, 287
Differences of male and female pelvis, 27
Difficult breathing during pregnancy, 161
Difficult labor, - - 248, 324, 344
ergot in, ... 329, 347
from agglutination of os uteri, 359
from ascites of fetus, - - 354
from calculus in the bladder, - 355
from cancer of the os uteri, - 359
from cauliflower tumor, - 359, 365
from cicatrix in the vagina, - 357
from delay of the child's head, 357
from distension by twins, - 328
from early departure of the chin, 387
from encysted tumors, - - 366
from excess of liquor amnii, - 328
from excrescences, - - - 366
from exostosis, - 361
from feces in the rectum, - 356
from fibrous tumors of the cer-
vix, 362

from fungus tumor, - - 365
from hydrocephalus, - - 352
from imperforate hj'men, - 356
from imperforate os uteri, - 359
from inefficient uterine contrac-
tions, - - - - 326, 345
from malpositions of the head, 387
from obliquity of os uteri, - 341
from obliquity of uterus, - 340
from oedema of labia majora, - 357
from ovarian tumor, - - 363
from pelvic deformity, - - 367
from pelvic osteo-sarcoma, - 361
from pelvic tumors, - - 360
from phlegmonous tumors, - 366
from polypus, - - - 362
from premature rupture of the

membranes, - 343

from rheumatism of the uterus, 329

from rigidity of membranes, - 342

from rigidity of os uteri, - 332

from rigidity of soft parts, 350, 337

from scirrhous tumors, - - 366

from shortness of the cord, - 351

from syphilitic vegetations, • 366

from toughness of membranes, 342

from tumors, - - - - 360

from tympanitis of the fetus, 354

from vaginal cystocele, - - 354

INDEX.

751

Difficult labor from vaginal hernia, 356
from vaginal vesicocele, - 354
in first stage, - 324^
in second stage, ... 344
breech, management of, - - 417

Dilatation of the os uteri, 246, 249, 265,
270, 336, 350

of os uteri by dry-cupping, - 350
of perineum, - - - - 254
Dimensions of the fetus, - 48, 232
Dimness of vision during pregnancy, 1G0
Discrimination of scalp from bag of

waters, ... 254,
Diseases of the fetus, - - -

of the pregnant female,
Distension from twins, -
Divisions of labor . - -

of the fetus, -
Dr. Washington on dry-cupping, -
Dressing the cord, -
Dropsy of ovum, -

Dry-cupping to cause dilatation of os
uteri, - - - - -
to cause uterine contraction, -
Duration of first stage of labor, -
of labor, - - - -
of pregnancy, -
of second stage of labor,
of third stage of labor, -
Duties of accoucheur, after delivery,
of accoucheur in the first stage

of labor, -
of accoucheur in the second stage

of labor, -
of accoucheur in the third stage
of labor, - - - -
Dwarfish pelvis, -
Dyspnoea during pregnancy,

263
237
143
328
248
48
350
285
176

350
350
252
242
98
254
255
282

256

270

277
33, 368
161

Embryotomy forceps, Meigs,
Encysted tumors, -
Enlargement of the abdomen,

of the breasts, -
Ephclis, - - -

Ephemeral fever, -

symptoms of, -

treatment of, -
Epigenesis, theory of, -
Epilepsy, - - - ' ■ .
Ergot, cautions respecting the use of,

400
401
402
401
401, 402

401,

in difficult labors, -
in natural labors, -
Evolution, spontaneous,
theory of,

329,

596
366
107
106
105
657
657
658

91
529
348
347
276
431

91

Ear presentations,

diagnosis of, -

management of,

positions of, -

treatment of, -
Early departure of the chin from the

breast, - 387

Eclampsia, 526

Effects of gelseminum, to overcome, 336

of loss of blood, - 333, 428, 495
Embryonic spot, - 81, 199

Embryotomy,

589

Examination, vaginal, ■

258

Excavation, — . —

25

Excess of lic[uor amnii,

328

Excessive locbial discharge,

293

Excoriated nipples, •

296

Excoriation of the navel,

671

Excrescences, - —

366

Exhaustion, symptoms of,

344,

479,

568

Exostosis, -

361

Expulsion of the head,

254,

274

of the placenta, •

255,

280

Extension, - - -

54,

312

External organs, - ■

55

Extra-uterine pregnancy,

101,

138

Exvisceration, • —

432

Face presentation,

303,

391

diagnosis of -

393

mechanism of,

395

positions of, -

303

treatment of, -

398

Fainting, - - -

160,

469,

524

Falling of the Womb, -

170, 299

Falopian tubes,

77

False pains, -

247

treatment of,

248

False pregnancy, -

101,

137

False waters,

174

201

Fecal accumulation,

356

Fecundation,

89

Feet, how to distinguish,

419

Feet presentation,

306

407

diagnosis of, -

419

treatment of, -

413

, 418

Female in natural labor,

249

organs of generation,

55

752

AMERICAN ECLECTIC OBSTETRICS.

Fetal apoplexy, -

279

asphyxia, - - -

278

circulation, -

_

229

dimensions and weight,

m

232

head, diameters of,

51

head, expulsion of,

254,

274

heart, beating of, -

_

110

respiration, -

229

scalp, to discriminate from

bag

of waters, -

254,

263

Fetus, and its development, -

213

ascites of,

_

354

attitude of, -

_

227

death of, ...

238

diseases of, -

237

full developed,

237

its divisions and dimensions

48

position of, -

227

signs of death of, -

238

tympanitis of,

354

violent movements of,

175

Fever, ephemeral,

657

irritative, -

509

miliary, -

659

milk, -

295,

657

puerperal, -

614

Fibrillar contractions, -

245

Fibrous tumors of the cervix,

362

Fifth position of vertex,

302,

320

Fillet,

550

First left cephalo-iliac position,

305,

420

diagnosis of, -

420

First position of vertex,

302,

309

First right cephalo-iliac position,

305,

420

diagnosis of, -

420

First stage of labor, - 248,

249,

258

condition of female in, -

249

condition of os uteri in,

252

condition of uterus in, -

251

conduct of accoucheur in,

260

duration of, -

252

inefficient contractions in,

326

management of,

258

mode of examination in,

259

rheumatism of uterus, in,

329

rigidity in, -

332

Flatulent colic of infants,

669

Fleshy moles, - - -

137,

184

Flexion, - - -

54,

310

Flooding [see Hemorrhage), -

455

Fluid, amniotic, -

201

Fontanelles, and sutures, - - 50
Food for the child, 298
Forceps, ----- 556
at the superior strait, 564, 582, 586
cases requiring, - - - 664

Davis', 557

Hodges" ... 558

in breech labors, - 587
in face presentations, - 584, 586
in left mento-iliac positions, - 584
in left occipito-anterior positions, 575
in left occipito-posterior positions, 578
in left occipito-transverse posi-
tions, - 580
in mento-pubic positions, - 585
in mento-sacral-positions, - 686
in occipito-posterior positions,

(breech labors,) - . 588

in occipito-pubic positions,

(breech labors,) - - - 587
in occipito-pubic positions, - 677
in occipito-sacral positions, 579, 588
in pelvic presentations, - 587
in right mento-iliac positions, 585
in right occipito-anterior posi-
tions, - - - - 576
in right occipito-posterior posi-
tions, - 579
in right-occipito-transverse posi-
tions ----- 681
in vertex presentation, - - 571
mode of applying, - - 569
period for applying, - - 566
rules for applying, - 564, 669
use of the, - - - 564

when not to be used, - - 565
when the face is at the superior

strait, - - - - 586
when the head is at the superior
strait, - 582, 586

Forehead toward pubic arch, 321, 389
Fossa navicularis, ... 62
Fourchette, . 58
Fourth position of vertex, - 302, 316
Frsenum, - 58
Full developed fetus, - - - 237
Fungous tumor. - - - - 365
Funis, ligature of, - 277
prolapsus of, - - - - 441

short, 361

umbilicalis, - - - - 211

INDEX.

753

Galvanic heat in inverted uterus, 519
Galvanism, in premature labor, - 611
Gastrodynia, during pregnancy, - 152
Gastrotomy (see Cesarean operation)
Gelseminum in abortion, - - 187
in cramps, - - - - 152
in gastrodynia, - 152
in hour-glass contraction, - 506
in inverted uterus, - - 518
in irregular contraction, ' - 506
in irritative fever, - - 510
in odontalgia, - - 158
in placenta praevia, - 467, 473
in preternatural labor, - 428, 429
in puerperal convulsions, - 536
in puerperal fever, - - 626
in puerperal mania, - - 648
in retained placenta, - - 510
in rheumatism of the uterus, 175, 332

in rigid os uteri,
in vomiting, -
inert, - - - -
to overcome the effects of,
General signs of pregnancy,
Generation, - - - -
Genitals, itching of,
pustules of, -
Germinal membrane, -
spot, -

vesicle, - - -
Gestation, duration of, -
Graafian vesicles,
Great sacro-sciatic ligament,

Habit of aborting,
Hand-presentation,
Hand and foot presentation,
Hare-lip, -

Head and extremity presenting,
delay of, in pelvic cavity,
descent of, -
extension of, -
flexion of,

impaction of, - note
mal-positions of, -
of child, diameters of, -
positions of, {see Vertex.)
presentations of, (see Vertex.)
presentations of side of,
restitution of,
rotation of

335
148, 246
336, 536
336
103

159,

80,

163
169
199
81
81
98
79
18

192
304
404
673
403
357
310
54, 312
54, 310
381, 566
387
51

400
276, 312
55, 311

Headache, during pregnancy, - 154
Heart, beating of fetal, - - HO
palpitation of, 160
Heartburn during pregnancy, - 151
Heat, galvanic in inverted uterus, 519
Hematemesis, - - - - 170
Hemoptysis, - 170
Hemorrhage, accidental, - - 478
accidental, diagnosis of, - 479
accidental, treatment of, - 480
after effects of, 495
after placental delivery, - 485
after placental delivery, symp-
toms of, 486
after placental delivery, treat-
ment of, 487
after the child's delivery, - 482
after treatment of, - - - 493
before full term, - 456
concealed, - 478
concealed, diagnosis of, - 479
concealed, treatment of, - 480
following abortion, - - 189
from the cord, - - - 671
from the navel, - 671
from placenta prsevia, treatment
v •- of, - 456, 461
in retained placenta, - - 482
in retained placenta, treatment of, 483
prevention of, - - - 495
puerperal - 455, 464
reaction of, - - - - 495
syncope^from, - - 469, 492
treatment of after-effects, - 493
unavoidable, - 456
uterine, - - - 455, 464
with abortion, - 177, 185, 189
with adherent placenta, 482, 506
with hour-glass contraction, - 502
with inverted uterus, - - 512
with irregular contraction, - 469
with placenta prsevia, - - 456
Hemorrhoids, - - - ■ 166
Hernia, - - - - " 1™
umbilical - 671
vaginal, - 356
Hodge's forceps, - 558
Holding the child, - - - 280
Hollow of the sacrum, - - - 11
Hour-glass contraction, - - 502
Hydatids, 137

754

AMERICAN ECLECTIC OBSTETRICS.

Hydrocele of infants, - 673

Hydrocephalus, - 352
Hydrorrhea, ... 174, 201

Hymen, ----- 61

Hymen, imperforate, ... 356

Hysterical convulsions. - 155, 527

Hysteritis ----- 621

Ilio-pectineal line - - - 14

Ilium, - - 14

Impaction of the head, - note 381, 566

Imperforate hymen, ... 356

os uteri, - - - 359

Impregnation, theories of, - - 88

Incontinence of urine, - - 169

Indications of mal-formed pelvis, 41

Induction of premature labor, - 601

Inertia of the uterus, - - - 485
Inefficient action of the uterus in the

first stage of labor, - - 326

in the second stage of labor - 345

Inert gelseminum, - - 336, 536

Infantile affections, - 666
Infants, (see Child.)

colic of, - - - - - 669
constipation of, 670
hydrocele of, - - - - 673
jaundice of, - - - - 668
ophthalmia of 669
retention of urine in, - - 668
swelled breasts of, - - 673
Inferior strait, - 24
axis of, - 25
diameters of, - - - - 24
plane of, 25
Inflammation of the breasts, - 653
symptoms of, - - - 654
treatment of, - - - - 654
Inflammation of the uterine ab-
sorbents, ... - 624
post mortem appearances of, - 624
symptoms of, - - - - 624
Inflammation of the uterine ap-
pendages, ... - 620
diagnosis of, - - - - 620
post-mortem appearances of, - 621
symptoms of, ... 621
Inflammation of the uterine veins, 623
post-mortem appearances of, - 624
symptoms of, ... 623
Inflammation of the uterus, - 621

Inflammatory pueperal fev

er, treat-

ment of,

-

-

626

Inner bark of cotton root,

329,

489,

612

Innominatum,

-

-

13

Insanity after delivery,

-

-

644

during pregnancy,

-

-

162-

Interstitial pregnancy,

-

-

142

Intestinal irritation,

-

-

650

diagnosis of,

-

-

651

prognosis of,

-

651

symptoms of,

-

650

treatment of, -

-

651

Introduction of catheter,

60,

131,

172

267, 291

326,

354,

570

Inversion of the uterus,

-

512

of the uterus, diagnosis of,

514

galvanic heat in, -

519

prognosis of, -

514

symptoms of, -

513

treatment of

515

Irregular contractions,

502,

508

Irritability, nervous, during preg-

nancy,

162

Irritative fever from putrid absorp-

tion, - - -

190,

509

Ischia, planes of, -

15

Ischium, -

10

Itching of the genitals,

159,

163

Jaundice, during pregnancy,

168

of infants,

668

Kiesteine, ...

109

Knee presentation,

306, 408

diagnosis of, -

418

treatment of,

419

Labia majora,

57

oedema of,

357

Labia minora,

58

Labia pudendi,

57

Labor, - - - -

242

attentions required after,

287,

299

cause of,

243

complicated, -

455,

469

condition of female infirststage of, 249
condition of female in second do., 252
condition of 03 uteri in first

stage of, - - - 251

condition of os uteri in second

stage of, - 262

i

INDEX.

755

Labor, condition of uterus in first stage

of, 251

conduct of accoucheur in first

stage of, - 260
conduct of accoucheur in second

stage of 270
conduct of accoucheur in third

stage of, 277
difficult, - - . 324, 344
difficult, ergot, in, - - 329, 347
difficult, in first stage, - - 324
difficult, in second stage, - 344
divisions of, - - - - 248
duration of, - - - - 242
duration of first stage of, - 252
duration of second stage of, - 254
first stage of, - - 248, 249
induction of premature, - 601
lingering, (see difficult Labor.)
management of natural, - 255
mechanism of, - 307
methods of inducing premature, 606
mode of examination in first

stage of, - - - - 259
Labor pains, 242, 246, 249

false, 247

true, 247

Labor, position for delivery in natu-
ral - - - - 259, 271
premature, ... 194, 601
premature, induction of, - - 601
premonitory signs of, - - 244
preternatural, - - 405, 419, 440
protracted, (see difficult Labor.)
rigors during, - 246
rules to determine the character of, 264
second stage of, - - 252, 270
tedious, ---- 248, 324
third stage of, - - 255, 277
treatment of cramps during, - 271
with pelvic deformity, treatment of, 369
difficult, from mal-positions of

the head, - 387
ergot in difficult, - - 329, 347
ergot in natural, - 276
treatment of difficult breech, - 417
treatment of twin, - 447

twin, 445

Laceration of perineum, - - 254
of vagina, - 523
Laxity of abdomen during pregnancy, 169

Left calcaneo-iliac position, - - 306
Left cephalo-iliac positions, - 305, 420
diagnosis of, - - - - 420

Left lobulo-iliac positions, - - 402
diagnosis of, - - - - 402

Left mento-iliac position, - 304, 395
diagnosis of, - - - - 393

mechanism of, - 395
Left-occipito-anterior position, 302, 309, 575
diagnosis of, - 309

forceps in, 575
mechanism of, - 309
Left occipito-posterior position, 302, 316
diagnosis of, ... 316

mechanism of, - - - 317
Left sacro-cotyloid position, - 306, 403
diagnosis of, - - - - 408

mechanism of, - - - - 409

Lesser sacro-sciatic ligament, - 18
Lever, ------ 551

Ligament, great sacro-sciatic, - 18
lesser sacro-sciatic, - - 18
Ligament, obturator, ... 19
Ligaments and articulations of pelvis, 17
Ligaments, broad, - - - - 75

of ovary, - 78
of uterus, .... 75

round, ----- 76

sacro-sciatic, - 18
Linea ilio pectinea, 14
Linear albicantes, ... 289

Lingering labor, (see difficult labor.)
Lip of os uteri, retention of anterior, 341
Liquor amnii, ... - 201
excess of, 328
Lobulo-pubal positions, - - 401, 402
Local signs of pregnancy, - - 103
Lochia, .... 255, 292

deficient, 294
excessive, - 293
Locked head, - - note 381, i>66
Longings during pregnancy, - 150

Making the bed, - 266

Malacostcon, .... 31

Male and female pelves, 27

Malformation of the pelvis, - 29, 367

indications of, ... 41

Malpositions of the head, - - 387

Mammary abscess, ... 653

Management of breech presentation, 413

756

AMERICAN ECLECTIC OBSTETRICS.

Management of difficult breech labors,

417

Milk fever, - - - -

295,

657

ear presentations, - 401,

403

Milk-leg. -

634

face presentation, -

398

Milk-scab, - - -

679

feet presentation, - - 413,

418

Milk, secretion of in pregnancy,

107

knee presentation,

419

Miscarriage, -

177

labor with pelvic deformity,

369

Mixed pregnancy, - 101,

134,

137

mento-iliac positions,

398

Mobility of the pelvic articulations,

19

monstrosities. - - -

454

Mode of applying the forceps,

569

natural labor, -

255

Mode of examination in first stage of

shoulder presentations,

422

labor, -

259

twin labors, — — -

447

Mode of performing craniotomy,

593

Mania during pregnancy, - -

162

Moles, -

137

puerperal, - - - -

644

fleshy, --- -

137,

184

Mastodynia, -

161

Mollities ossium, - - -

31

Measurement of the pelvis,

42

Mons veneris, -

56

Meatus urinarius, -

60

Monsters, -

136,

453

Mechanism of labor, -

307

Monstrosities, management of,

454

left mento-iliac position,

395

Morbid adhesion of placenta,

506,

508

left occipito-anterior position,

309

treatment of,

507

left occipito-posterior position,

317

Morph, -

105

left sacro-cotyloid position,

409

Mother's marks, -

672

occipito-pubal position, -

316

Muco-serolent discharge,

245

occipito-sacral position, -

321

Mucous discharges from vagina,

169

richt mento-iliac position.

397

Multiple pregnancy, - 101,

134,

445

right occipito-anterior position,

315

Muscular pains during pregnancy,

162

right occipito-posterior position,

321

right sacro-cotyloid position, -

412

Ncevus materni, -

672

sacro-pubic position, »

412

Nasal catarrh, -

681

sacro-sacral position,

412

Natural labor, position for delivery,

259

Meconium, - - - - —

237

Nausea during pregnancy,

103

Meconium, purging the,

286

Navel, excoriation of -

671

Meig's embryotomy forceps, -

596

hemorrhage from. -

671

Membrana caduca. - - -

195

Navel string, ...

211

decidua, - - - -

195

Nervous irritability during pregnancy, 162

Membrane, caducous, ...

195

Nervous shock, ...

288

deciduous, -

195

Nine-day fits, -

678

germinal, ... go,

199

Nipple, excoriated,

296

vitelline, -

80

sore, - - - -

296

Membranes, premature rupture of,

343

sore, treatment of, -

296

ricriditv of, -

342

Nursing sore mouth,

660

0 rupture of, ... 251,

343

NymphEe, - - - -

58

toughness of, -

342

Menstruation, -

93

Obliquely distorted pelvis, -

36,

368

suppressed, a sign of pregnancy,

104

Obliquity of os uteri, -

341

Methods of inducing premature labor

606

of uterus, -

340

Metritis, - - - - -

621

Obstetrical instruments,

544,

600

post-mortem appearances of, -

622

Obstetrical operations,

544

613

symptoms of, -

621

Obturator foramen,

15

Miliary fever, ....

659

ligament, -

19

symptoms of,

659

Occipital positions,

302,

309

treatment of, -

660

Occipito-pubal position, 302, 315, 587

INDEX.

757

Occipito-pubal position, diagnosis of,

315

l ains, preparatory,

249

mechanism of,

~

316

treatment of false,

9<1S

Occipito-sacral position,

303,

Palpation, abdominal, -

llt>
ili

diagnosis of, - -

321

Palpitation of the heart,

lull

mechanism of,

■

321

Parietal pregnancy,

Odontalgia during pregnancy,

158

Parturition, -

CLdema during pregnancy,

164

Pathology of puerperal

convul-

(Edema of labia majora,

357

sions, - - -

528,

OoO

Omphalo-mesenteric vessels,

204

Pelvic articulations, mobility of,

Operation, Cesarean,

597

Pelvic cavity, diameters of,

9£

Operation of craniotomy,

589

planes of,

9ft

Operative midwifery,

554,

613

tumors in,

OOU

Ophthalmia of infants, •

669

Pelvic deformities, difficult labor from,

OD f

Organs of generation, -

55, 63

management of labor with,

369

Orifice of the urethra, - -

60

Pelvic presentations,

305,

405,

587

basilare, - -

10

diagnosis of, -

408

Os coccyx, -

13

management of,

413

Os ilium, — — — -

14

mechanism of,

*X\JV

Os ischium -

15

Pelvic symphyses,

16

Os pubis, -

15

Pelvimeter, Baudelocque's,

Os uteri, - - - -

68

Coutoully's, -

{, agglutination of,

359

Pelvimetry, - - -

42

cancer of,

359

Pelvis, - - - -

10

descent of, -

341

abnormally large, -

- 33,

367

dilated by dry cupping, -

350

articulations of,

17

dilatation of, 246, 249, 265, 270, 336

350

axis of, -

26

Os uteri, imperforate. -

359

bones of,

9

obliquity of, -

341

brim of, -

- 14

23

obliteration of,

359

cavity of,

- 10, 22

25

retention of anterior lip,

341

deformities of,

29,

367

; ! rigidity of, in first stage of la-

diameters of, -

26

bor, -

252,

332

dwarfish,

- 33,

368

rigidity of, in second st age of labor, 350

Pelvis, indications of malformatio

n of,

41

Ossa innominata, -

13

obliquely distorted,

-36,

368

Osteo-sarcoma of pelvis,

361

osteo-sarcoma of, -

361

Ovaries, -

77

straits of,

22

Ovarian pregnancy,

140

unequally contracted,

-34,

368

Ovarian tumor, -

363

Pendulous belly, -

283

Ovular theory, ...

92

Perforator, - - -

592

Ovule, or human egg, -

- 79

80

Perineum, - - -

62

Ovum, development of, -

195

dilatation of, -

254

dropsy of,

176

rigidity of,

-62,

337,

350

support to the,

-62,

274

Pain in the right side during preg-

Period for applying forceps,

566

nancy, _ . .

168

for turning, -

547

Pain, muscular, during pregnancy,

162

Peritonitis, -

617

Painless uterine contractions,

245

Phlebitis, crural, -

634

Pains, after, - - - -

290

uterine, - - -

623

false, -

247

Phlegmasia dolens,

634

irregular, - - -

502,

508

'■>' causes of,

634

of labor, - - 242,

246,

249

diagnosis of, -

639

758

AMERICAN ECLECTIC OBSTETRICS.

Phlegmasia dolens, post-mortem ap-

Position, left mento-iliac, diagnosis of,

393

pearances of,

639

left mento-iliac, mechanism, -

395

prognosis of, -

G39

left occipito-anterior, - 302,

675

symptoms of, -

oo t

left occipito-anterior, diagnosis

treatment of, -

639

of

309

Phlegmonous tumors,

366

left occipito-anterior, mechan-

Piles during pregnancy,

166

ism of, -

309

Placenta, - - -

208

left occipito-posterior, - 302,

316

adherent, - - 499,

502,

506

left* occipito-posterior, diagno-

delivery of,

255,

280

316

detachment of, - 484,

499,

504

left occipito-posterior, mechan-

expulsion of, -

255,

280

317

hemorrhage after delivery of,

485

left sacro-coty loid, - — 306,

409

symptoms of hemorrhage after

left sacro-cotyloid, diagnosis of.

408

delivery of,

486

left sacro-cotyloid, mechanism of,

409

treatment of hemorrhage after

A^/>inUn_TMlVifll m SO/

587

delivery of,

487

occipi to-pubal, diagnosis of, —

315

morbid adhesion of,

506

occipito-pubal, mechanism of,

316

Placenta prsevia, - - -

456

occipi to-sacral, — — 303,

321

diagnosis of, -

458

A/i/i!v\! i r\ oo/^vnl fi i n tr Yin Q nf —
U ltl k llUo 13 Ul,

321

hemorrhage from, -

456

occipi to-sacral, mechanism of,

321

treatment of, -

461

of the fetus, * • • ™

227

putrescence of,

190,

509

right c ale an eo-i liac, — —

306

retained, -

497

right mento-iliae, — — 304,

585

retained, treatment of, 499,

507,

510

right mento-iliac, dia-gnosis of,

393

retention of, -

4Q7

right mento-iliac, mechanism of,

397

retention of from irregular con-

virrli f o^pnnfn.nn tprinv — SO/

lli^LlL. tbtl|J!WJ illl IC1 1U1 j UViij

314

traction, -

508

right occipito-anterior, diagnosis

retention of from morbid adhe-

OI,

314

sion, - - - -

506

vicrVif r\f*n 1 tm f n_*i ti f pvl a y* ty> o n o T\ ~

retention of from uterine inertia,

499

ism of, - - — -

315

Placental presentation, -

456

Y*i (t n t nc*/M Yii f n-.Y^r\Q t pti f\Y* S09
1 Igilt ULl/ 1^} 1 L \) ^f\J o IC l 1U1 , uviij

320

sound, - - - -

109

1 1 g 11 \j Uttl^lLU"^>Uo IC1 1U1 j vl 1 <1 ^ 11 U

Plane of inferior strait,

25

of the superior strait,

24

right occipito-posterior, media n-

Planes of the ischia,

15

icm r»r* 309 390
lo 111 01, — - 0\J£. O^U]

321

of the pelvic cavity,

25

right sacro-coty loid, — 306,

412

Plethora during pregnancy, -

156

right sacro-cotyloid, diagnosis of,

4Uo

Plurality of children, -

445

right sacro-cotyloid, mechanism

Podalic version, -

422,

545

ot,

Polypus, -

362

sacro-pubic, — — — 306,

412

Porrigo larvalis, -

679

sacro-pubic, diagnosis of, -

408

treatment op-

680

sacro-pubic, mechanism of, -

419.

position, first left cephalo-iliac,

305,

420

sacro-sacral, - — - 306,

41 9

first right cephalo-iliac, -

305,

49n

sacro-sacral, diagnosis of,

4H8

first vertex, -

302,

sacro-sacral, mechanism of, -

41 9

fifth vertex, -

302,

320

second left cephalo-iliac, 305,

420

for delivery in natural labor

259,

271

second right-cephalo-iliac, 305,

420

fourth vertex,

302,

316

second vertex, - - 302,

314

left calcaneo-iliac, -

306

sixth vertex, - - 303,

321

left mento-iliac,

304,

584

third vertex, ; - - 302,

315

>

INDEX.

759

Positions and presentations,

300

Pregnancy, falling of the womb dur-

left lobulo-iliac,

402,

403

ing, -

170

eft lobulo-iliac, diagnosis of, 402,

403

101

137

lobulo-pubal,

401

ft^fol tyi n v ATn pn t Q (111V1T1(T
1 L I il 1 X1LU V C1HCI1 to UU111J£^,

108,

175

lobulo-pubal, diagnosis of

401

gastrodynia during, —

152

mento-iliac, treatment of,

398

general signs of — —

103

of breecli presentation, —

306,

409

headache during, - —

154

of ear presentations,

401

heartburn during, -

151

of face presentation,

304,

391

hematemesis during,

170

of feet presentation,

306,

407

hemoptysis during,

170

of shoulder presentations,

305,

419

hemorrhoids during,

166

of vertex presentation, -

302,

309

hernia during,

176

right lobulo-iliac, -

401,

403

hydrorrhea during,

174

right lobulo-iliac, diagnosis

of,

incontinence of urine during,

169

401,

403

insanity during,

162

Post-mortem appearances of inflam-

interstitial, -

142

mation of uterine appendages,

621

jaundice during, - -

168

appearances of inflammation of

laxity of abdomen during,

169

uterine veins,

624

local signs of, - *

103

appearances of metritis,

622

longings during,

150

appearances of phlegmasia, dolens,

639

mania durin°", - -

162

appearances of puerperal

peri-

mastodynia during,

_

161

tonitis, -

620

mixed, - 101,

134,

137

Posterior commissure of the vulva,

58

multiple, - - -

101,

134

Pregnancy, - - -

98

muscular pain during, -

162

abdominal, - - - -

138,

141

nausea during,

105,

145

affections of the bladder during,

159

nervous irritability during,

162

anorexia during, -

149

odontalgia during,

158

anteversio uteri during,

173

oedema during,

164

areola in,

106

ovarian, - - - -

140

audible signs of, -

109

pain in right side during,

168

calculus during, -

176

palpitation during,

160

cardialgia during,

151

parietal, -

142

cephalalgi dur ng,

154

piles during, -

166

changes in the uterus durin

g.

117

plethora during,

156

compound, - - 101

134,

445

prolapsus ani during, -

167

constipation during,

153

prolapsus uteri during, -

170

convulsions during,

155

prurigo during,

163

cough during,

161

pruritus of vulva during,

163

cramp of stomach during,

152

ptyalism during, -

148

cramps during,

167

pustules of genitals during,

169

despondency during,

162

rational signs of -

103
170

diarrhea during, -

150

retroversion of uterus durin

Si

difficult breathing during,

161

rheumatism of the uterus during,

175

diseases of

143

rigidity of abdomen during,

169

dimness of vision during,

160

salivation during, -

148

dropsy of ovum during,

176

secretion of milk during,

107

duration of, -

98

sensible signs of, -

103,

106

dyspnoea during, -

161

signs of,

101

extra uterine,

101,

138

sound of fetal heart during,

110

fainting during, -

160

spasm of stomach during,

152

760

AMERICAN ECLECTIC OBSTETRICS.

Pregnancy, spasm of ureters during,

159

Presentations, management of vertex,

262

spasm of uterus during,

174

of an extremity with the head,

403

sub-peritoneo-pelvic, ~

142

of the breech,

305,

405

suppressed menses during,

104

of the face, - - -

303,

391

sympathetic signs of,

103

of the feet, - - -

306,

407"

syncope during, — —

160

of the knees,

306,

408

synopsis of signs of, ™

132

of the pelvic extremities,

305,

407

syphilis during, — —

176

of the shoulder,

304,

419

table of signs of, ■ ~

132

of the side of the head, -

400

tangible signs of, ■ -

110

placental, -

456

toothache during, - -

158

position of the breech, -

306

,409

treatment of extra-uterine,

142

positions of ear,

401

tubal, -

141

positions of face, -

304

tubo-abdominal, — —

142

positions of shoulder.

305

tub o -ovarian.

142

positions of vertex,

302

176

transverse, -

440

110,

136

turning in shoulder,

422

n i pi*n-t n Ttn 1 — - —

UliClU'lUUdl, —

142

vertex, - 301,

302,

307

utero-tubo-abdominal,

142

Pressure on the aorta, -

490

vaginal dicharges during,

169

Preturnatural labor, - 405,

419,

440

varicose veins during,

165

Prevention of hemorrhage. -

495

ventral, - - - -

141

Prognosis of abortion, -

182

vertigo during,

160

of intestinal irritation, -

651

vomiting during, -

105,

145

of inverted uterus,

514

with pelvic deformity, -

601

of phlegmasia dolens, -

639

Pregnant female, diseases of,

143

of puerperal convulsions,

534

Premature labor, -

194,

601

of puerperal fever,

624

modes of inducing,

608

of puerperal mania,

647

Premature rupture of the membranes,

343

of ruptured uterus,

521

Premonitory signs of labor, -

244

Prolapsus ani, during pregnancy,

167

Preparatory pains,

249

of the cord, -

441

Presentations and positions,

300

of the cord, diagnosis of,

442

compound, -

403

of the cord, treatment of,

442

diagnosis of breech,

408

uteri, during pregnancy,

170

diagnosis of ear, -

401

Promontory of the sacrum, -

12

diagnosis of face, -

393

Protracted labor, (see Difficult Labor.)

diagnosis of foot, -

419

Prurigo during pregnancy, -

163

diagnosis of knee, -

419

Pruritus of the vulva during preg-

diagnosis of pelvic,

408

nancy, -

163

diagnosis of placental, -

458

Ptyalism during pregnancy, -

148

diagmosis of shoulder, -

420

Pubic arch, - - -

16

diagnosis of transverse,

440

Pubic symphysis, - - -

16,

17

diagnosis of vertex

307

Pubis, os, -

15

management of breeeh, -

413

Puerperal convulsions,

526

management of ear,

401,

402

causes of,

529

management of face,

398

diagnosis of, -

527,

534

management of feet,

413,

418

pathology of,

528,

535

management of knee,

419

prognosis of, -

534

management of placental,

461

symptoms of,

531

management of shoulder,

422

treatment of,

635

management of transverse,

441

Puerperal fever, -

614

INDEX. '

761

Puerperal, fever, causes of,-

615

Right mento-iliac position, -

304,

685

prognosis of, -

624

diagnosis of, -

393

treatment of, -

625

mechanism of,

397

Puerperal hemorrhage, -

455,

464

Right occipito-anterior position,

302, 314

Puerperal mania,

644

diagnosis of, -

314

causes of,

644

mechanism of,

315

diagnosis of, -

646

Right occipito-posterior posi-

prognosis of, -

647

tion, - - -

302,

320

symptoms of, -

645

diagnosis of, -

320

treatment of, -

647

mechanism of,

321

Puerperal peritonitis, -

614,

617

Right sacro-cotyloid position,

306,

412

diagnosis of, - - / -

619

diagnosis of, -

408

post-mortem appearances of,

620

mechanism of,

412

symptoms of, -

617

Rigid abdomen during pregnancy,

169

Puerperal phrenitis,

644

Rigidity of the membranes, -

342

Pulse, vaginal, -

131

of the os uteri,

252,

332

Pulsation of the fetal heart, -

110

of the perineum, - 62,

337,

350

Purging the meconium,

286

of the soft parts, - 62,

337,

350

Pustules of genital organs, during

of the vagina,

337,

350

pregnancy, 1

169

Rigors during labor,

246

Putrefactive absorption,

190,

509

Rotation of the head, -

54,

311

Putrescence of placenta,

190,

509

Round ligaments, -

76

Putting to bed, - - -

284

Rules for applying the forceps,

564

569

Rules for determining the character

Quickening, - - - -

108

of labor, -

264

Rupture of the bladder,

523

Rational signs of pregnancy,

_

103

of the cord, -

508

Reaction of hemorrhage,

495

of the membranes,"

251,

343

Red gum, - - - -

668

of the membranes, premature,

343

Relaxation of the symphyses,

20

of the uterus,

519

Repiration, fetal,

229

of the uterus, diagnosis of,

521

Restitution of the head,

275,

312

of the uterus, prognosis of,

521

Retention of the anterior lip of

OS

of the uterus, symptoms of,

520

uteri, - - - -

341

of the uterus, treatment of,

522

Retention of the placenta, -

497

of the vagina,

523

from irregular contractions,

508

from morbid adhesion, -

506

Sacro coccygeal symphysis, -

19

from uterine inertia,

499

iliac symphyses,

17

treatment of, - - 499,

507,

510

pubic position,

306,

412

with hemorrhage, -

482

pubic position, diagnosis of,

408

Retention of ujyne, - 159,

291,

326

pubic position, mechanism of,

412

of urine in infants,

668

sacral position,

306,

412

Retroversion of the uterus,

170

sacral position, diagnosis of,

408

Rheumatism of the uterus, 175

291,

329

sacral position, mechanism of,

412

Rickets, -

30

sciatic ligaments, -

18

treatment of,

30

Sacrum, -

2.10

Right calcaneo-iliac position,

306

hollow of,

li

cephalo-iliac positions, -

305,

420

Sacrum, promontory of,

12

diagnosis of, -

420

Salivation during pregnancy,

148

Right lobulo-iliac positions, -

401,

403

Scirrhous tumors,

366

diagnosis of,

401,

403

Second position of vertex, -

302,

314

49

762

AMERICAN ECLECTIC OBSTETRICS.

Second stage of labor,

248,

252

Spot germinal, -

_

81

condition of female in, -

252

Stages of labor, -

-

249

condition of os uteri in,

252

Still-born children,

-

278

conduct of accoucheur in,

270

Strait, inferior, -

-

24

difficult, - - -

-

344

axis of, -

-

25

duration of, -

-

254

diameters of,

-

24

inefficient contractions in,

345

plane of, -

-

25

left cephalo-iliac position

305

Strait, superior, -

-

23

management of,

270

axis of, -

-

24

right ceplialo-iliac position,

305

diameters of, -

-

23

rigidity in, -

350

plane of, -

-

24

Secretion of milk during pregnancy,

107

Straits of the pelvis

-

22

Section, Cesarean,

_

597

Strophulus intertinctus,

_

668

Sensible signs of pregnancy,

103,

106

Sub-peritoneo-pelvic pregnancy,

-

142

Separation of the symphyses,

_

20

Subsidence of the abdomen, -

244

treatment of,

21

of the uterus,

244

Shock to the nervous system,

_

288

Superfetation, -

134,

240

Shortness of the cord, -

_

351

Superior strait, -

-

23

Shoulder presentations,

304,

419

axis of, -

_

24

cephalic version in,

433,

545

diameters of, -

_

23

diagnosis of, -

_

420

plane of, -

-

24

management of,

_

422

Support to the perineum,

62,

274

positions of, -

305,

419

Suppressed menses in pregnancy,

104

turning in, -

_

422

Sutures and fontanelles,

-

49

Show, -

_

245

Swelled breasts of infants, -

-

673

Signs of labor, premonitory,

_

244

Sympathetic signs of pregnancy,

103

Signs of pregnancy,

101

Symphyseotomy, - - -

600

audible, - - -

109

Symphyses, pelvic,

17

death of fetus,

238

Symphysis sacro-coccygeal, -

19

general, ...

103

Symphysis, sacro-iliac,

17

local, -

103

pubis, - - - -

- 16

17

rational, ...

103

Symptoms indicating interference,

sensible, -

103,

106

344,

499,

568

sympathetic, -

103

of abortion, -

180

synopsis of, -

132

of aphthae, -

675

table of, ...

132

of cyanosis, -

667

tangible, - - -

110

of ephemeral fever,

657

Sinking of the uterus, -

244

of exhaustion, - 344,

499,

568

Sixth position of vertex,

303,

321

of hemorrhage after delivery,

486

Snuffles, -

681

of inflammation of the breasts,

654

Soft parts, rigidity of, - 62,

337,

350

of inflammation of the uterine

Sore-mouth of nursing women,

660

absorbents,

624

Sore nipples, ...

296

of inflammation of the uterine

Sound of fetal heart, -

110

veins, -

623

Sound placental, - - -

109

of intestinal irritation, -

650

Spasm of stomach, during pregnancy,

152

of inverted uterus,

513

of ureters, during pregnancy,

159

of metritis, -

622

of uterus, during pregnancy,

174

of miliary fever, -

659

Spine of the ischium, -

15

of nursing sore-mouth, -

661

Spontaneous evolution,

431

of phlegmasia dolens,

637

Spot embryonic, - - -

81,

199

of puerperal convulsions,

531

INDEX.

763

Symptoms of puerperal mania, - 645

of puerperal fever, - - 617

of puerperal peritonitis, - 617

of rupture of the uterus, - 520

of uterine phlebitis, - - 623

Syncope during labor, - 524

during pregnancy, - - 160

from hemorrhage, - - - 469

Synopsis of signs of pregnancy - 132

Syphilis as a cause of abortion, 179, 191

during pregnancy, - - 176

Syphilitic vegetations, - - 366

Table of signs of pregnancy, - 132

Tache embryonnaire, - 199

Tampion, - - - 186, 188, 466

Tangible signs of pregnancy, - 110
Tedious labor, (see Difficult Labor.)

Theories of impregnation, - - 88

Theory of epigenesis, - 91

of evolution, - 91

ovular, ----- 92

Third position of vertex, - 302, 315
Third stage of labor, - - 255, 277

conduct of accoucheur in, - 277

Thrombus, 525

treatment of, - 525

Thrush, 675

Tongue-tied infants, - - - 672

Tooth-ache during pregnancy, - 158

Toughness of the membranes, - 342

Tractor, 551

Transverse presentations, - - 440

Treatment of abortion, - - 184

of accidental hemorrhage, - 180

of after effects of hemorrhage, 493

of aphthae, - - - - 676

of breech presentations, - 413

of concealed hemorrhage, - 480

of convulsions, - 528

of ooryza, - 682

of cramps during labor, - 271

of cyanosis, - - - 667

of difficult breech labors, - 417

of difficult labors, - 248, 324, 344
of ear presentations, - 401-403

of ephemeral fever, - - 658

of extra uterine pregnancy, - 142

of face presentations, - - 398

of false pains, - 248
of foot presentations, 413, 418

Treatment of hemorrhage after delivery, 487

of hemorrhage before term, 184, 456
of hemorrhage from placenta

prasvia, ... - 461
of hemorrhage with retained pla-
centa, - 483
inefficient action of uterus, 326, 345
of inflammation of the breasts, 654
of inflammatory puerperal fever, 626
of intestinal irritation, - - 651
of inverted uterus, - - 515
of knee presentations, - - 419
of labor with pelvic deformity, 367
of men to-iliac positions, - 398
of miliary fever, - 660
of monstrosities, - 454
of natural labor, - 255
of nursing sore-mouth - - 662
of obliquity of uterus, - - 341
of ovarian tumor, - - - 364
of phlegmasia dolens, - - 639
of placenta prsevia, - - 461
of porrigo larvalis, - - 680
of prolapsed cord, - - - 442
of puerperal convulsions, - 535
of puerperal fever, - - 625
of puerperal hemorrhage, 455, 464
of puerperal mania, - - 647
of puerperal peritonitis, - 625
of reaction after hemorrhage 496
of relaxation of symphyses, - 21
of retained placenta, 499, 507, 510
of rheumatism of the uterus, - 331
of rickets, - 30
of rigidity of os uteri, - 252, 333
of rupture of the uterus, - 522
of separation of the symphyses, 21
of shoulder presentations, - 422
of sore nipples, - 296
of thrombus, ... 525
of transverse presentations, - 440
of trismus nascentium, - - 679
of twin labors, - - - 447
of typhoid puerperal fever, - 630
of unavoidable hemorrhage, - 461
Tremors during labor, - - - 246
Trismus nascentium, - 678
treatment of, - - - - 679
True labor-pains, - - - - 247
Tubal pregnancy, - - - 141
Tubes, Fallopian, - - - 77

764

AMERICAN ECLECTIC OBSTETRICS.

Tubo-abdominal pregnancy,

142

Uterine phlebitis, - - - -

623

Tubo-ovarian pregnancy,

_

142

diagnosis of, -

624

Tumor, cauliflower,

365

post-mortem appearances of, -

624

fibrous, -

362

symptoms of, -

623

fungous, - - -

365

Uterine prolapsus, during pregnancy,

170

ovarian, - - -

m

363

Uterine veins, inflammation of,

623

phlegmonous,

366

Utero-tubal pregnancy,

142

scirrhous, -

366

Utero-abdominal preguancy,

142

Tumors during pregnancy, -

362

Uterus, ------

66

in difficult labor, -

360

anteversion of during pregnancy,

173

in pelvic cavity,

360

broad ligaments of,

75

Turning, - - - -

422,

546

changes in during pregnancy,

117

cases for, -

546

condition in first stage of labor,

251

dangers of, -

549

diagnosis of inverted, -

514

in shoulder presentations,

422

diagnosis of ruptured, -

521

period for, -

547

galvanic heat in inverted,

519

Twins, ---- 134,

328, 445

hour-glass contraction of,

502

diagnosis of, -

135,

446

inefficient action of, - 326,

345

distension from,

328

inflammation of, -

621

Tympanites, acute

650

inversion of, -

512

Tympanitis of the fetus,

354

ligaments of, -
obliquity of, -

^ J 7

75
340

Ulcerated nipples,

296

prognosis of inverted, -

514

Umbilical cord, - - 211, 277, 285

prognosis of ruptured, -

521

cutting the, - - -

278

rheumatism of, * - 175, 291,

329

prolapsus of, -

441

retroversion of during pregnancy,

170

shortness of, - - -

351

round ligaments of,

76

treatment of prolapsed cord

442

rupture of, -

519

Umbilical hernia,

671

sinking of, -

244

vesicle, -

203

spasm of during pregnancy, -

174

Unavoidable hemorrhage,

456

subsidence of, -

244

treatment of, -

461

symptoms of inverted, -

513

Unequally contracted pelvis,

34,

368

symptoms of ruptured, -

J 1 — * t 7

520

Unruptured hymen,

356

treatment of inverted, -

515

Urachus, -

205

treatment of ruptured, -

522

Ureters, spasm of during pregnancy,

159

Urethra, orifice of the -

60

Vagina, -

63

Urine, attention to, 258, 265, 267,

291,

326

cicatrix in, -

357

incontinence of,

169

laceration of, -

523

retention of in infants, -

668

rigidity of, - - - 337,

350

Use of ergot, cautions respecting,

348

rupture of, -

523

Use of the forceps,

564

Vaginal cystocele, -

354

Uterine absorbents, inflammation of,

624

examination in first stage of labor,

258

Uterine appendages, inflammation of,

620

hernia, - - -

356

Uterine contractions, - -242,

289,

345

mucous discharges,

169

by dry cupping, -

350

pulse, - - - - -

131

painless, - - - -

245

vesicocele, -

354

JJtcrine hemorrhage,

455,

464

Varicose veins during pregnancy,

165

treatment of, 461, 470, 480, 483, 487

Vectis, ------

551

Uterine inertia, with hemorrhage,

485

Vegetations, syphilitic,

366

with retained placenta,

482,

499

Ventral pregnancy, - - ■

141

INDEX.

765

Vernix caseosa, - 226, 236,

[280,

[284

Vomiting during pregnancy, 105,'

145

Version, -

545

Vomiting in labor, -

246

cephalic,' ...

433,

545

Vulva, -

57

podalic, ....

422,

546

anterior commissure of,

57

Vertex presentation^ -

301

posterior commissure of,

58

diagnosis of, -

307

pruritus of, -

163

forceps in, -

_

571

mechanism of,

309,

323

Washing the child, -

284

positions of, -

302,

321

Washington, Dr., on dry-cupping,

350

Vertigo during pregnancy, -

m

160

Waters, bag of,

251

Vesicle, blastodermic, -

199

bag of, to distinguish from fetal

germinal, -

81

scalp, --- - 254,

263

umbilical, -

203

false, - - - - 174,

201

Graafian, - - -

79

Weed,

657

Vesicula umbilicalis,

203

Weight and dimensions of the fetus,

232

Vessels, omphalo-mesenteric,

204

Woman in labor, ... 249,

257

Vestibulum, - - -

59

Womb, falling of. -

170

Violant fetal movements,

175

Wright, Prof. M. B., on cephalic $

Vital changes in the uterine tissues

version, -

433

during pregnancy,

123

Vitelline membrane,

,80

Yelk, or vitellus, - - - -

80

Vitellus, or yelk, - - -

"80

INDEX TO SIXTH PAET.

Achillea millefolium,

Page 684

Ammonia, muriate of, -

687

Acid gallic, - - - -

684

Ammonia? hydrochloras,

687

Acid tannic, -

685

Anthcmis nobilis,

688

Acid um gallicum,

684

Antispasmodic tincture,

725

Acidum tannicum,

685

Apium petroselinum, -

688

Aconitum napellus,

685

Apocynum cannabinum,

688

Aletridin, -

686

Argenti nitras, -

689

Aletris farinosa, -

686

Aristolochia serpentaria,

689

Aloe socotrina, ...

686

Arnica montana, -

689

Alo"s,

686

Asclepias tuberosa,

690

Althrca officinalis,

687

Asclepidin, - - - -

690

Alum root, - - - -

719

Assafoetida, - -

690

Amaranth, - - - -

687

Atropa belladonna,

691

Amaranthus hypochondriacus,

687

American hellebore,

742

Balsam, parturient,

694

Ammonia, chloro-hydrate of,

687

Balsam, styptic, - - -

729

766

AMERICAN

ECLECTIC OBSTETRICS.

1

Baptisia tinctoria, - 692

Baptisin, - 692

Bath, spirit vapor, - 740

Belladonna, ----- 691

Beth root, - - - - - 741

Bidens bipinnata, - 692

Bitters, restorative wine, - - 703

Blackberry, - - - - - - 735

Black cohosh, - 701

Bloodroot, ; 736

Blue cohosh, - 694

Blue flag, 723

Borate of soda, - - - - 739

Borax, ------ 739

Brake, buckhorn, - 730

Brake, rock, ... - 734

Buckhorn brake, - - - - 730

Buckwheat, 732

Calcined deer's horn, - - - 703

Calx, 692

Camphor, ----- 693

Camphora, ----- 693

Canada fleabane, - 706

Capsicum annuum, - 693

Catnip, ----- 729

Caulophyllin, ... 695

Caulophyllum thalictroides, - - 694

Caustic, lunar, - 689

Caustic of Filhos, 692

Caustic, Vienna, - - - - 692

Cayenne pepper, - 693

Ceanothus Americanus, - - 696

Cedar, red, 724

Cephaelis ipecacuanha, - - 696

Chamomile, ----- 688

Chloroform, - - - - - 697

Chloroformum, - 697

Chloro-hydrate of ammonia, - 687

Cimicifuga racemosa, - - - 701

Cimicifugin, 702

Cinnamomum Zeylanicum, - - 702

Cinnamon, ----- 702

Cleavers, ----- 707

Coffea Arabica, 703

Coffee, 703

Cohosh, black, 701

Cohosh, blue, - 694
Compound powder of ipecacuanha

and opium, - 693

Compound syrup of partrigeberry, 728

Compound tincture of iodine, - 722

Compound tincture of lobelia, - 726
Compound tincture of lobelia and

capsicum, - - - - 725
Compound tincture of Virginia

snakeroot, - - - - 689

Compound wine of comfrey, - 703

Convallaria multiflora, - - 703

Cordial, mother's, - 728

Cornu cervinse calcinatum, - - 703

Cotton-plant, - 718

Cramp-bark, - - - ' - 743

Cranberry, high, - - - - 743

Crawley, 734

Cypripedin, - 704

Cypripedium pubescens, - - 704

Ditura stramonium, - 705

Deer's horn, calcined, - - - 703

Dewberry, ----- 735

Diaphoretic powder, ... 693

Dioscorea villosa, - 705

Dioscorein, ----- 705

Elixir proprietatis, - 686

Erechthites hieracifolius, - - 706
Ergot, - - - note, 708, 737

Erigeron Canadense, - 706

Expectorant tincture, - - - 726

False unicorn root, - 719

Female regulator, - 738

Feverfew, ----- 735

Fireweed, ----- 706

Firing, 706

Five finger, ----- 734

Flag, blue, 723

Fleabane, Canada, - 706

Galium aparine, - - - - 707

Gallic Acid, 684

Galvanism, ----- 707

Gelseminum sempervirens, - - 716

Geraniin, ----- 718

Geranium, ----- 717

Geranium maculatum, - - 717

Gossypium herbaceum, - - 718

Htemastasis, - - - - 718

Haii'cap moss, - 733

Hedeoma pulegioides, - 719

INDEX.

767

Hellebore, American, -

742

Maruta cotula, - - - -

727

Helonias, - - - -

719

May weed, - - -

727

Helonias Dioica, -

719

Mel, - - -

727

Hemp, Indian, -

688

Mitchella repens, - - - -

728

Henbane, - - -

721

Monkshood, - - - - -

685

Heuchera Americana, -

719

Morphia, solution of sulphate,

731

Hibiscus, marsh, - - -

687

Mother's cordial, - - - -

728

Hibiscus palustris,

687

Motherwort, - -

725

High Cranberry, -

743

Muriate of ammonia, -

687

Honey, -

727

Hops, - - - - -

720

Nepeta cataria, -

729

Humulus lupulus,

720

Nitrate of silver, - - - -

689

Hyoscyamus niger,

721

Hypericum perforatum,

721

Oil of tui-pentine, -

729

Oleum terebinthinse, -

729

Indian hemp, -

688

Opium, ------

730

Indigo, wild, -

692

Osmunda regalis, - - - -

730

Iodine, - — - -

722

Iodine pills, - - - -

722

Papaver somniferum, - - -

730

lodinium, - - - -

722

Parsley, - - - - -

688

Ipecacuanha, -

696

Partridgeberry, - - - -

728

Iridin, - - - - -

723

Parturient balsam, -

694

Iris versicolor, -

723

Pennyroyal, -

719

Iron weed, -

743

Pepper, cayenne, - - - -

693

Pepper, water, -

732

Jessamine, yellow,

716

Pleurisy-root, -

690

Juniperus sabina,

728

Podophyllin, -

731

Juniperus Virginiana,

724

Podophyllum peltatum,

731

Polygonum fagopyrum,

733

Kalmia augustifolia,

724

Polygonum punctatum,

732

Krameria triandria,

724

Polytrichum juniperum,

733

Poppy, ------

730

Ladies-slipper, yellow, -

704

Potentilla Canadensis, - - -

734

Laurel, sheep, -

724

Powder of ipecacuanha and opium,

Leonurus cardiaca,

725

compound, -

693

Leopard's bane,

689

Privet, ------

725

Life-root, -

738

Pteris atropurpurea, -

734

Ligustrum vulgare,

725

Pterospora andromeda,

734

Lime, - -

692

Pyrethrum parthenium,

735

Lobelia, -

725

Lobelia inflata, - - -

725

Raspberry, red, - - - -

735

Lunar caustic, - - -

689

Red cedar, - - - - -

724

Lupulin, -

720

Red raspberry, - - - -

735

Red-root, -

696

MacrMin, -

702

Restorative wine bitters,

703

Madder, -

735

Rhatany, -

724

Mallow, marsh, -

687

Rock-brake, - - - - -

734

Mandrake, -

731

Rosemary, marsh, -

741

Marsh hibiscus, -

687

Rubia tinctorium, -

735

Marshmallow, - - -

687

Rubus strigosus, -

735

Marsh rosemary, -

741

Rubus trivialis, - - - -

735

768

AMERICAN ECLECTIC OBSTETRICS.

Rubus villosus, - - ' - 735

Rue, - - -* - - - 736

Ruta graveolen3, - 736

St. Johnswort, .... 721

Sal ammoniac, - 687

Sanguinaria Canadensis, - - 736

Sanguinarin, - - - - - 736

Sarracenia, - - - - - 736

Sarracenia purpurea, - 736

Savin, 723

Scullcap, 737

Scutellaria lateriflora, - 737

Scutellarine, ..... 737

Secale cornutum, ... - 737

Senecio aureus, .... 738

Senecio gracilis, - - - - 738

Senecin, - - - 738

Sheep-laurel, .... 724

Silver, nitrate of, - - - - 689

Snakeroot, Virginia, ... 689

Soda, borate of, - - - - 739

Sodae boi-as, ----- 739

Solomon's seal, - 703

Solution of sulphate of morphia, - 731

Spanish needles, - - - - 692

Spirit of turpentine, - 729

Spirit vapor-bath, ... 740

Statice Caroliniana, - 741

Stramonium, - - - - 705

Styptic balsam, - - - 729

Sudorific tincture, - r - 689

Syrup of partridgeberry, compound, 728

Tanacetum vulgare, ... 741

Tannic acid, j - 685

Tansy, 741

Terebinthinse oleum, ... 729

Tincture, antispasmodic, - - 725

Tincture of iodine, compound, - 722

Tincture of lobelia, compound, - 726
Tincture of lobelia and capsicum,

compound, - 725
Tincture of Virginia snakeroot,

compound, - - - 689

Trillium pendulum, - 741

Turpentine, oil of, - - 729

Turpentine, spirit of, - - 729

Unicorn-root, - 686

Unicorn-root, false, - - 719

Valerian, - - - - - 741

Valeriana officinalis, ... 741

Vapor-bath, spirit, ... 740

Veratrum viride, - - - * 742

Vernonia fasciculata, - 743

Viburnum opulus, - 743

Vienna caustic, - 692

Virginia snakeroot, - 689

Water-pepper, - 732

Wild indigo, ... 692

Wild yam, 705

Wine bitters, restorative, - - 703

Wine of comfrey, compound, - 703

Winter-fern, . ... 294

Yam, wild, 705

Yarrow, 684

Yellow jessamine, - 716

Yellow ladies-slipper, - 704

THE END.

SEP 1 5 1959 >+B